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Motor Car Insurance
Fire Insurance
Property Floater Insurance
Travel Insurance
Personal Accident Insurance
Money Insurance
Marine Cargo Insurance
Annual Inland Marine Cargo Insurance
Fidelity Guarantee
Surety Bonds
Comprehensive General Liability Insurance
Motor Car Insurance Form
CLOSE
DETAILS OF VEHICLE CERTIFICATE OF REGISTRATION (C.R)
TIN
YEAR / MODEL / MAKE
SERIES / BODY TYPE
SERIAL / CHASSIS NO.
MOTOR / ENGINE NO.
PLATE NUMBER
COLOR
CURRENT MARKET PRICE
Php
ACCESSORIES
Please check / declare accessories if applicable
Standard Built-In Accessories
Front Bullbar
Rear Bullbar
Stepboard
Ladder
Top Carrier
Others
TRANSMISSION
MANUAL (M/T)
AUTOMATIC (A/T)
FUEL
GASOLINE
DIESEL
CATEGORY
SURPLUS VEHICLE
RECONDITIONED
LOCALLY MANUFACTURED CAR
ASSEMBLED
VEHICLE USAGE
PRIVATE
Use only for social, domestic, pleasure purposes and for the insured profession.
LTO / FOR HIRE
Use for vehicle for Carriage of PASSENGERS.
COMMERCIAL
Utility vehicle use in business owned for hauling/loading and transporting what PARTICULAR products or items?
UPLOAD PICTURE
Photos of Unit, Certificate of Registration, etc.
FIRE INSURANCE FORM
GUEVENT INSURANCE BROKER CORP.
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CLIENT ASSURED DETAILS
Mailing Address
PROPERTY DETAILS
Location of Property
No. of Storeys
Age of the Building
Estimated Floor Area
TYPE OF HOME
Single Detached
Town House
Condo Unit
Duplex
Apartment
EXTERIOR WALLS
All Concrete
Concrete with Timber
All Timber
Others
ROOFING MATERIALS
GI Sheets
Ceramic / Tegula Tiles
Hard Roof Deck
Others
Boundaries / Surroundings: Street / Road name, description / occupancy of building etc.
Rear
Right
Left
Front
Are you the Registered Owner ?
Yes
No
Any Previous loss? (Fire, flood, earthquake, typhoon, etc.)
No
Yes
INSURANCE COVERAGE DETAILS
SUM INSURED
Building
Contents ( excluding cash, jewelries , watches , paintings , antiques , work of arts)
Others
Total Sum Insured
UPLOAD PICTURE
Photos of the house inside and out.
PROPERTY FLOATER INSURANCE FORM
GUEVENT INSURANCE BROKER CORP.
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DETAILS OF OWNER AND UNIT DESCRIPTION
TIN
YEAR / MODEL / MAKE
TYPE OF BODY
SERIAL / CHASSIS NO.
MOTOR / ENGINE NO.
COLOR
CURRENT MARKET PRICE
Php
USAGE AND LOCATION OF RISK
Quarry
Non-Quarry
USED FOR
PROJECT SITE / S
LOSS FREE VERIFICATION
Any history of claim?
Does the unit have pre-existing damage/s?
UPLOAD PICTURE
TRAVEL INSURANCE FORM
GUEVENT INSURANCE BROKER CORP.
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CLIENT ASSURED DETAILS
TRIPGUARD INDIVIDUAL
TRIPGUARD FAMILY
ANNUAL
SHORTSECURE (Non-Air Domestic)
Travel Including USA/Canada/HKG
Travel Excluding USA/Canada/HKG
Philippine Travel Only
Individual
Group
Nationality
Principal Applicant's Passport No.
TIN/SSS/Driver's License I.D. No.
TRAVEL INSURANCE FORM
Purpose of Trip
Select One
Visit Relatives
Business(i.e. attending conference or meeting)
Short-term Study
Leisure
Others
If others, please specify
VIEW BENEFITS
PERSONS TO BE INSURED
AGE
BIRTHDATE
PLAN
BENEFICIARY
RELATIONSHIP TO INSURED
- Choose One -
EXECUTIVE PESO
DE LUXE PESO
PRIVILEGE PESO
EXECUTIVE DOLLAR
EXECUTIVE DE LUXE PESO
PRESTIGE EURO
PRESTIGE PLUS
- Choose One -
EXECUTIVE PESO
DE LUXE PESO
PRIVILEGE PESO
EXECUTIVE DOLLAR
EXECUTIVE DE LUXE PESO
PRESTIGE EURO
PRESTIGE PLUS
- Choose One -
EXECUTIVE PESO
DE LUXE PESO
PRIVILEGE PESO
EXECUTIVE DOLLAR
EXECUTIVE DE LUXE PESO
PRESTIGE EURO
PRESTIGE PLUS
- Choose One -
EXECUTIVE PESO
DE LUXE PESO
PRIVILEGE PESO
EXECUTIVE DOLLAR
EXECUTIVE DE LUXE PESO
PRESTIGE EURO
PRESTIGE PLUS
- Choose One -
EXECUTIVE PESO
DE LUXE PESO
PRIVILEGE PESO
EXECUTIVE DOLLAR
EXECUTIVE DE LUXE PESO
PRESTIGE EURO
PRESTIGE PLUS
Mode of Payment
CASH
CHECK
ITINERARY
COVER TO COMMENCE FROM
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
01
02
03
04
05
06
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09
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11
12
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14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TO
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
FOR
Day
1 Day
2 Days
3 Days
4 Days
5 Days
6 Days
7 Days
8 Days
9 Days
10 Days
11 Days
12 Days
13 Days
14 Days
15 Days
16 Days
17 Days
18 Days
19 Days
20 Days
21 Days
22 Days
23 Days
24 Days
25 Days
26 Days
27 Days
28 Days
29 Days
30 Days
31 Days
PERSONAL ACCIDENT INSURANCE FORM
GUEVENT INSURANCE BROKER CORP.
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DETAILS OF EMPLOYER
PROFESSION OR OCCUPATION
NATURE OF WORK
ANNUAL INCOME
Beneficiary
Relationship
Do you have any physical defect or infirmity of any kind or have you ever had diabetes, tuberculosis varicose veins, and disease of the heart or brain, amputation, impairment of hearing of sight or any nervous affection ?
During the last 5 years, have you been hospitalized or consulted a physician for any reason ?
NO
YES , Please give details
NO
YES , Please give details
With what company (ies) and for what amounts are you at presently insured ? ( Life / Personal Accident )
Have you ever claimed or received compensation under any accident or sickness policy ?
NONE
COMPANY (IES)
NO
YES , Please give details
MONEY INSURANCE FORM
GUEVENT INSURANCE BROKER CORP.
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CLIENT ASSURED DETAILS
Nature Business
Business Address
No. of years in the business
Required Coverage
SECTION I - Money Inside Premises
SECTION II - Money Outsdide Premises / Money In Transit
SECTION III - Payroll Money Inside and Outside Premises
For SECTION II / III - Money Payroll In Transit
For SECTION I / III - Money Payroll Inside Premises
a ) Frequency of Carryings
a ) Location of premises to be insured
b ) Amount of money involved
b ) Amount of money involved
c ) Transit Routes ( From , To )
c ) Details of security measures within the premises
d ) Mode of Transportation
d ) Loss experience for the past 3-5 years ( as may be applicable )
e ) Details of security measures taken during money transits
f ) Loss experience for past 3-5 years ( as may be applicable )
MARINE CARGO INSURANCE FORM
GUEVENT INSURANCE BROKER CORP.
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CLIENT ASSURED DETAILS
Description of Cargo
Conveyance
L / C No.
Fax No
Origin
Destination
Mortgagee
Departure Date
Arrival Date
Amount of Insurance
Bill of Lading / Airway Bill No
ANNUAL INLAND MARINE CARGO INSURANCE FORM
GUEVENT INSURANCE BROKER CORP.
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DESCRIPTION / TRANSIT DETAILS
Interest Insured
Limit Per Truck
Aggregate Limit
Transit / Route
Frequency
Loss Experience
Previous Insurer
Effectivity of Cover
TRUCK SPECIFICATION (Please use separate column if necessary)
TYPE OF TRUCK
PLATE NUMBER
MOTOR NUMBER
SERIAL NUMBER
CREW DETAILS (Pls. do not leave blank)
Drivers Employed
Are all drivers and helpers regular employees?
Yes
No
Helpers Employed
How many are not?
Please specify hiring process for :
Drivers
Direct Hire
Agency
Helpers
Direct Hire
Agency
Substitute
Direct Hire
Agency
Has there been occasion to question the honesty/conduct of persons to be hired?
Yes
No
FIDELITY GUARANTEE INSURANCE FORM
GUEVENT INSURANCE BROKER CORP.
CLOSE
CLIENT ASSURED DETAILS
Nature Business
No. of years in the business
Business Address
Employees to be Guaranteed
NAME
POSITION
LENGTH OF SERVICE
AMOUNT OF COVERAGE
What are the duties and responsibilities with regard to money matters and / or stocks / inventory and / or office equipment ?
Do you conduct a background investigation of your employees prior to hiring? If yes, please give examples. If no, please explain why.
Period of Cover
Loss experience for the past 3-5 years (as may be applicable). What measures were adapted to prevent similar happenings ?
SURETY BOND FORM
GUEVENT INSURANCE BROKER CORP.
CLOSE
The undersigned hereby applies for a bond described as follows
NAME OF THE COMPANY
BUSINESS ADDRESS
KIND OF SURETY BOND
Please select one..
Bid Bond
Performance Bond
Downpayment Bond
Warranty Bond
Replevin Bond
Attatchment Bond
Injuction Bond
Guardian's Bond
AMOUNT
Php
OBLIGEE
Condition of the Bond is to guarantee
If a Contractor, please attach :
Copy of the Contract for the bond being applied
Notice of award
Notice to proceed
In what other lines of business do you have a financial interest ? Please state :
Have you secured a bond before ?
No
Yes
Bonding Company
Amount
Obligee
Period
Date Terminated
Have you ever had an application declined by any Surety Company ?
If so, when and why?
If there is any person (agent or broker) who reffered our company to you, please state the name and the agency he/she represents.
COMPREHENSIVE GENERAL LIABILITY INSURANCE FORM
( Office Premises / Retail Stores / Contract Works )
GUEVENT INSURANCE BROKER CORP.
CLOSE
CLIENT ASSURED DETAILS
Business Address
Nature of Business
Description of Business ( Please choose one )
Office
Hotel
Showroom
Factory
Warehouse
Retail Store / Shop
Project Contractor
Shopping Mall
Others, please specify
No. of years in the business
Total Floor Area Occupied
Sqm
Estimated Sales Revenue
If coverage required is for Contract Works, what is the . . .
Limit of Liability required ( Coverage )
Contract Value
Bodily Injury
Php
Scope Works
Property Damage
Php
Project Location
Aggregate Limit
Php
Period of cover
Loss experience for the past 3-5 years ( as may be applicable )
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