Fax this completed form to OMNI at: (632) 810-0761

OMNI Group of Companies

(Insurance Brokerage Services – Since 1971)

OMNI International Consultants, Inc.  OMNI Expat Benefits Association, Ltd.  OMNI Capital (Far East), Ltd.

Office Comprehensive Purchase Form

Where/How did you learn of OMNI?
Proposer’s Name / Tel
Contact Person / Fax
Trade or occupation / e-mail
Address
Describe bldg. Construction & #stories?
Type of roof? / Security? / Occupied as?

Describe surroundings with distances to, type of structures and what nearby buildings are occupied as:

Front / Rear
Left / Right
Property / Financial Items to be insured / Sums Insured in Philippine Pesos
Contents: (furniture, equipment, supplies, etc.) (entry required
Permanent Leasehold Improvements, etc. (entry optional)
Officer’s / Employee’s property (See note 1) (entry optional)
Property of others that is in your care (See note 1) (entry optional)
Other Contents (See note 2) (entry optional)
Additional Expenses if loss occurs (See note 3) (entry optional)
Business Interruption: (See note 4) (below items optional)
Annual Standing Charges following a LOSS
Payroll Amount to be insured
Annual NET Profit

notes: 1. Property of others in your office and care may be insured by declaring owner/s names and by providing listing of item descriptions

and values. Employee’s property may be declared in single total amount except items valued over P5,000. List separately such

items valued over P5,000 each to include description and owner’s name.

2. Other office contents may be product samples, sales materials or others. Attach a list with descriptions and values.

3. Extra expenses caused by a loss can be covered as additional rent, tempo staff, equipment leasing, overtime, temporary

communications, additional travel & other extraordinary expenses directly resulting from an insured peril of the policy.

4. Business Interruption covers those ongoing standing charges or costs including payroll that you will incur following a loss.

Payroll can be insured for varying percentage amounts over the period of insurance cover i.e. 100% for 6mo & then 50%

for next 6mo, etc.

Total Annual Premium Cost inclusive of Taxes and Policy Fee

Place the insurance quoted herein as accepted by my signature below

Attach Check Payable to “OMNI Insurance Brokers” or await invoice

Signature of

Proposer Date

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Please read next page, which does not need to be faxed
Please read this page, which does not need to be faxed

IMPORTANT INFORMATION!

  • OMNI will confirm receipt of this request for insurance purchase/placement. Only insurance companies can approve or reject your request for final policy placement --based upon the particulars you have supplied. OMNI will send to you details of the insurance company’s official confirmation.
  • You MUST complete, originally sign and return this purchase form to OMNI by mail or courier. It will be forwarded to the insurance company for acceptance and policy issuance. Applications for early temporary cover will be expedited.
  • Complete details of the coverage are stipulated in the actual Policy documents provided by the insurance company. These must be thoroughly read by all policyholders.
  • Refer to the OMNI Business Terms for further guidance, if needed.

OMNI Capital or OEBA / OMNI International Consultants
4/Floor Galuxe Bldg., 8-10 On Lan St. / 3/F Corinthian Plaza Bldg., 121 Paseo de Roxas St.,
Central Hong Kong / Legaspi Village, Makati Philippines 1262
Tel: (852) 2523-2767 Fax: (852) 2810-1957 / Tel: (632) 810-0487 Fax: (632) 810-0761

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