PI Medical Malpractice Registered Vets Proposal Form
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222, The Strand, Gzira GZR1022, Malta
You have requested a quote for our Motor Insurance cover. We will first ask you a few additional questions to determine whether the specific product we offer in this category aligns with your demands and needs.
Do you live on the Maltese Islands on a permanent bases or is your entity registered in Malta? YesNo
Are you the owner or intend to own a motor vehicle registered in the Maltese Islands?YesNo
Do you have a valid European driving licence?YesNo
Do you need insurance protection for your motor vehicle and/or cover for third party liability?YesNo
Based on your responses we can offer you the Insurance product subject to underwriting. You can now press on the ‘Next Step’ button to proceed with the quotation.
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All question require to be answered with a "Yes"
Cover RequiredThird Party OnlyThird Party Fire and TheftComprehensive Who will be driving the vehicle?Insured OnlyInsured and SpouseAny Driver Aged 25 and overAny Driver Aged 21 and overAny Driver Have you made a claim in the last 5 years?YesNo
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You have requested a quote for our Home Insurance cover. We will first ask you a few additional questions to determine whether the specific product we offer in this category aligns with your demands and needs.
Are you a Maltese citizen or the owner of (or intend to own) a property situated in the Maltese Islands? YesNo
Do you intend to use this property as a private residence?YesNo
Is the property left unoccupied for more than 90 consecutive days?
YesNo
Are your premises protected by an alarm and subject to an annual maintenance contract?
Do you have other current policies with Bonnici Insurance Agency / Mapfre Middlesea plc?
Have you or any members of your family usually residing with you suffered any loss or damage from any cause within the past 5 years?
You have requested a quote for our Commercial Home Insurance cover. We will first ask you a few additional questions to determine whether the specific product we offer in this category aligns with your demands and needs.
Do you live in the Maltese Islands on a permanent basis?YesNo
Are you the owner of a rental investment properly situated in the Maltese Islands?YesNo
Do you require insurance protection for material damage to the property and third party liability?YesNo
You have requested a quote for our Travel Insurance cover. We will first ask you a few additional questions to determine whether the specific product we offer in this category aligns with your demands and needs.
Do you live in the Maltese Islands on a permanent basis? YesNo
Are you travelling or intend to travel from the Maltese Islands and returning to the Maltese Islands within a specified period?YesNo
Are you travelling for pleasure and/or business purposes?YesNo
Do you require insurance protection for a single trip not exceeding 180 days?YesNo
How many persons, ordinarily resident in Malta, are travelling? (Age 0-69)12345678910 Where to and for how long are you travelling?Area 1: EuropeArea 2: Worldwide, Excluding USA & CanadaArea 3: Worldwide From: 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 202220232024202520262027 To: 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 202220232024202520262027 Which cover do you want:BudgetEconomyClub
Do you and/or the persons to be insured live in the Maltese Islands on a permanent basis?YesNo
Do you require insurance protection for the fees and expenses incurred during recognized medical treatment?YesNo
Based on your responses we can offer you the Health Insurance product subject to underwriting. You can now select to proceed with the process, and proceed to next page on this form to fill out customer details.
I / We do not have a pre-existing Medical Condition
I / we acknowledge that Bonnici Insurance Agency Ltd (BIA) and / or Mapfre Middlesea plc (MMS) may process the personal data that I/we provide in accordance with the Data Protection Act (Cap 440) and with the Data Protection Policy of the Company.
Is your business entity registered and operating in the Maltese Islands or are you a taxable person residing in the Maltese Islands? YesNo
Do you already have or intend to have a property insurance policy in place?YesNo
Do you require insurance protection against loss of income you may incur and/or increase in cost of working, should you be unable to carry on with your business activities due to material losses or damage to the property insured?YesNo
Based on your responses we can offer you the Business Interruption Insurance product subject to underwriting. You can now select to proceed with the process, and proceed to next page on this form to fill out customer details.
SMEProfessional IndemnityFire and PerilsTheftCommercial VehicleMarine CargoMoneyEmployers LiabilityPublic LiabilityElectronic EquipmentHoteliers CombinedGroup HealthContractors “All Risks”Group Personal AccidentBusiness TravelGroup Life
I/we acknowledge that Mapfre Middlesea plc (MMS) may process the personal data that I/we provide in accordance with the Data Protection Act (Cap 440) and with the Data Protection Policy of the Company.
I/we acknowledge that I/we have a right to request to and rectification of such data as processed by MMS. Any such request must further be signed by myself as the applicant/joint assured/joint holder to whom the personal data relates.
Are you the owner or intend to own a vessel?YesNo
Do you intend to mainly use the vessel in the Maltese Islands?YesNo
Based on your responses we can offer you the Marine Hull Insurance product subject to underwriting. You can now select to proceed with the process, and proceed to next page on this form to fill out customer details.
Comments/Suggestions How did you hear about us?
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Do you and/or any persons to be insured reside in the Maltese Islands on a permanent basis?YesNo
Are you and/or any persons to be insured aged between 18 and 65 years?YesNo
Do you require a financial benefit to be payable in the event of an accident?YesNo
Based on your responses we can offer you the Personal Accident Insurance product subject to underwriting. You can now select to proceed with the process, and proceed to next page on this form to fill out customer details
Do you hold a valid qualification and/or warrant and/or licence? YesNo
Do you practice your profession or business operation solely in the Maltese Islands? YesNo
Do you require insurance protection for sums which you may become legally liable to pay, arising from a claim made against you by reason of any negligent act,error or omission, occurring or committed in good faith in connection with your profession or business operation? YesNo
Based on your responses we can offer you the Professional Indemnity Insurance product subject to underwriting. You can now select to proceed with the process, and proceed to next page on this form to fill out customer details.
SubjectGeneralHomeHealthTravelBusinessProfessional IndemnityBoat InsurancePersonal AccidentClaims
