Arranged By:
AVA INSURANCE BROKERS PTE LTD
91 Bencoolen Street #08-03
Sunshine Plaza Singapore 189652
Tel: +65 6535 1828 Fax: +65 6535 6898
Company’s Registration No. 200706523M
Spa, Beauty and Wellness Insurance (For Prepaid Packages)
Pre-Enrolment Underwriting Application Form
1) Statement pursuant to Section 25 (5) of the Insurance Act (Cap. 142) or any amendments
thereof:
You are to disclose in this application form fully and faithfully all facts which you know or ought
to know, otherwise the Policy issued may be void.
2) No insurance is in force until this application is accepted by the Insurer in accordance to
policy terms, conditions and exclusions.
3) Insurer reserves the right to request for more documents/information after assessing this
application.
Insured Company Details:
Name of Insured Company:
____________________________________________________________________
Registered Address:
____________________________________________________________________
Name of Contact Person: _______________________________________________
Designation of Contact Person: ___________________________________________
Office No. ________________________ Handphone No.______________________
Email Address: ________________________________________________________
Please state no. of years your business has been established: ___________________
Services Rendered (please tick):
Spa Services
Massage Services
Manicure/Pedicure
Foot Reflexology
Facial & Beauty
Wellness Services
Slimming Services
Personal Training
Others Services, please state: _________________________________________
Estimated Annual Total Revenue: S$_______________________________________
Estimated Annual Revenue from Pre-Paid Packages: S$________________________
AXA INSURANCE SINGAPORE PTE LTD
8 Shenton Way, #27-01 AXA Tower, Singapore 068811
Customer Care: #B1-01
GST Registration No.: M2-0009922-2 Co. Registration No.: 196900406D
Arranged By:
AVA INSURANCE BROKERS PTE LTD
91 Bencoolen Street #08-03
Sunshine Plaza Singapore 189652
Tel: +65 6535 1828 Fax: +65 6535 6898
Company’s Registration No. 200706523M
Total Limit /Sum Insured Required for this Application: S$________________________
Outlets Details:
Total No. of Outlets: ___________________________________________________
Total No. of Operational Staff (e.g. Therapists, Consultants, Trainers etc.) but exclude Office
Administrative Staff: _______________________________________________
Please list all your outlets details as below:
(To attach separate listing if insured company has more than 5 outlets)
1)
Name of Headquarter Outlet: _________________________________________
Address: _________________________________________________________
Is the above outlet CaseTrust accredited? (please tick)
2)
Yes
No
Name of Outlet: ___________________________________________________
Address: _________________________________________________________
Is the above outlet CaseTrust accredited? (please tick)
3)
Yes
No
Name of Outlet: ___________________________________________________
Address: _________________________________________________________
Is the above outlet CaseTrust accredited? (please tick)
4)
Yes
No
Name of Outlet: ___________________________________________________
Address: _________________________________________________________
Is the above outlet CaseTrust accredited? (please tick)
5)
Yes
No
Name of Outlet: ___________________________________________________
Address: _________________________________________________________
Is the above outlet CaseTrust accredited? (please tick)
AXA INSURANCE SINGAPORE PTE LTD
8 Shenton Way, #27-01 AXA Tower, Singapore 068811
Customer Care: #B1-01
GST Registration No.: M2-0009922-2 Co. Registration No.: 196900406D
Yes
No
Arranged By:
AVA INSURANCE BROKERS PTE LTD
91 Bencoolen Street #08-03
Sunshine Plaza Singapore 189652
Tel: +65 6535 1828 Fax: +65 6535 6898
Company’s Registration No. 200706523M
Other Underwriting Information:
Average/Estimated No. of Prepaid Package Customers Per Year: _________________
Average Value of Package Signed by Customer: ______________________________
Average Duration of each Package: _________________________________________
Average No. of Treatment Room Per Outlet: _________________________________
Type of Facilities Available (please tick):
Jacuzzi
Gym
Sauna/Steam Room
Swimming Pool
Shower/Locker Room
Exercise Classroom
Spa Lounge
Others, please indicate: ________________________________________
Mode of Customers’ Record Keeping (please tick):
Book/Paper/Card Recording
Software System
Others, please indicate: ________________________________________________
Document Checklist:
Please attach the following documents as part of application and underwriting process:
No.
1.
2.
3.
4.
5.
6.
7.
8.
Required Documents
ACRA Report (with litigation information) of the Company
You may check and print from the below website:
https://www.sccb.sg/ddp/ddp_CusProductList.faces
Individual Search on All Directors (individual's business interests, litigation
information (High and Subordinate Courts) and Bankruptcy Trace)
You may check and print from the below website:
https://www.sccb.sg/ddp/ddp_CusProductList.faces
Audited Financial Statement &/or CTC Management Financial for Past 2 Years
A copy of CASE Trust Accreditation Certificate (if any)
A copy of Lease Agreement for Insured Outlets (Must be more than 6 months)
A copy of latest 2 Months Rental Receipt for Insured Outlets
4 photographs of outlets (massage/treatment rooms,
reception/waiting/lounge/locker area)
Notice of Assessment (Tax Assessment) of Directors/Shareholders for the latest
2 years
AXA INSURANCE SINGAPORE PTE LTD
8 Shenton Way, #27-01 AXA Tower, Singapore 068811
Customer Care: #B1-01
GST Registration No.: M2-0009922-2 Co. Registration No.: 196900406D
Please Tick if
Attached
Arranged By:
AVA INSURANCE BROKERS PTE LTD
91 Bencoolen Street #08-03
Sunshine Plaza Singapore 189652
Tel: +65 6535 1828 Fax: +65 6535 6898
Company’s Registration No. 200706523M
Declaration:
1)
2)
3)
I/We hereby declare that the particulars of this application/declaration are true and correct, and agree that
this application shall form part of the Policy Contact between me/us and the Insurer.
I/We have not withheld any undisclosed material and/or financial facts.
I/We declare that all Directors/Shareholders are in good health and insured company is free from any
financial difficulties.
Personal Data Collection Statement
AVA Insurance Brokers Pte Ltd (“we”, “our” or “us”) collects your personal data for the purposes of our
business functions and providing you the products/services that you have requested. If you provide us with
personal data relating to third parties, you confirm that you have obtained the requisite consent from such
third parties for our processing of their personal data. We take reasonable safeguards to ensure that all
personal data is kept secure in accordance with the standards set out in Singapore’s Personal Data
Protection Act 2012. Should you require any clarifications on how we handle your personal data, or if you
wish to request access or amendment/correction to your personal data, or if you wish to withdraw any
consent with respect to your personal data that you had given us previously, please contact our data
protection officer at dpo_brokers@ava-ins.com. You may wish to visit our website, www.ava-ins.com to
review our Privacy Policy.
I confirm that the information I have provided is my personal data and, where it is not my personal data,
that I have the consent of the owner of such personal data to provide such information.
By providing this information, I understand and give my consent for AXA Insurance Singapore Pte Ltd
and AXA Life Insurance Singapore Pte Ltd (collectively “AXA”), their respective representatives or agents
and AVA Insurance Brokers Pte Ltd (“AVA”) to:
a. Collect, use, store, transfer and/ or disclose the information, to or with all such persons (including any
member of the AXA Group or any third party service provider, and whether within or outside of
Singapore) for the purpose of enabling AXA to provide me with services required of an insurance
provider, including the evaluating, processing, administering and/ or managing of my relationship
and policy(ies) with AXA, and for the purposes set out in AXA’s Data Use Statement which can be
found at http://www.axa.com.sg (“Purposes”).
b. Collect, use, store, transfer and/ or disclose personal data about me and those whose personal data I
have provided from sources other than myself for the Purposes.
c. Contact me to share with me information about products and services offered by AXA that may be of
interest to me by post and e-mail and
By telephone
By fax
__________________________________
Authorized Signature and Company Stamp
Name/Designation:
Date:
AXA INSURANCE SINGAPORE PTE LTD
8 Shenton Way, #27-01 AXA Tower, Singapore 068811
Customer Care: #B1-01
GST Registration No.: M2-0009922-2 Co. Registration No.: 196900406D
By text message”