Fire Protection Impairment Form | Chubb Insurance Malaysia Berhad

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Completing this Form

All impairments to re protection equipment should be recorded and strictly controlled by site management. This form should be used

to notify Chubb Insurance Malaysia Berhad when re protection systems (sprinkler systems, re detection systems, gaseous agent re

suppression systems, etc.) are impaired in accordance with the following criteria:

• Impairment/isolation exceeds 8 hours duration or extends overnight, or

• Impairment/isolation of any primary re water supply (city water mains and re pumps), or

• Impairment/isolation aecting more than 25% of the complex/building.

The completed form should be emailed to Chubb using the links provided herein. The relevant section of the form should be completed and

further notication provided once adequate protection is restored.

Section A – to be completed by the Insured

Insured Name:

Location/Site Address:

Systems Impaired:

Smoke Detectors Thermal Detectors Fire Pumps

Alarm Panel Alarm Connection Water Supply

Sprinklers Hydrants Other:

Description of Impairment:

Reason for Impairment:

Impairment Start Date: Time:

Impairment End Date: Time:

Impairment Reported By:

Name:

Title: Phone:

Email:

Please indicate the precautions by local management below:

Fire brigade notied?

Managers and/or supervisors in the impaired area notied?

Is the impaired area monitored by a heat/smoke detection system?

Are additional re extinguishers available in the impaired area?

Is hydrant/hose reel system operational in the impaired area?

Are additional security patrols or a re watch in place?

Have hazardous operations such as hot work been discontinued?

N/A

Yes

Additional Precautions or Comments:

Fire Protection

Impairment Form

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Section B – to be completed by Chubb

Additional Recommended Actions:

Submitted By:

Date: Phone:

Section C – to be completed by the Insured once Fire Protection Systems are Restored

Date System Restored:

Restoration Notied By: Phone:

Privacy Notice

If you are providing personal data to Chubb Insurance Malaysia Berhad (Chubb), please read the following:

The Protection of Your Personal Data is Important to Us

We, Chubb, are committed to protecting your personal data and respect the privacy of individuals and the use of their personal data. We will deal

with your personal data in compliance with the requirements of the Personal Data Protection Act 2010 (“PDPA”) and ensure that any personal data

we collect about you is treated with the appropriate degree of protection and condentiality.

What Personal Data Do We Collect?

Depending on the purpose, we may collect personal data that includes but is not limited to your name, date of birth, NRIC number, gender, family

status, occupation, address including e-mail address, telephone number, nancial details (including credit card or other payment details), previous

and current insurance experience, and information relating to your insurance requirements.

We may also collect sensitive personal data, such as details about your health or condition, if any and if necessary.

Why Do We Collect Personal Data?

We collect and process personal data for the purpose of processing your insurance application/proposal, provision of insurance related products

or services or any addition, alteration, variation, cancellation, renewal or reinstatement thereof, performing statistical/actuarial research or data

study, promoting products and services, and other related purposes (collectively, “Purpose”).

How Do We Collect Personal Data?

We will only collect personal data by lawful and fair means. We collect personal data from time to time, when you ll up documents; liaise with

us or our representatives; or give it to us or our representatives in person, over the telephone, through websites or from third parties you have

consented to.

Consequence of Not Providing Us Your Personal Data

Although you are not obliged to provide us with your personal data, we will not be able to process your application for insurance cover or process

your claim if you fail to provide all requested information.

Disclosure to Third Parties

Your Personal Data may be disclosed to any related company or any other company carrying on insurance or reinsurance related business, an

intermediary, a claims, investigation or other service provider and to any association, federation or similar organisation of insurance companies

that exists or is formed from time to time for the Purpose or to full some legal or regulatory function or is reasonably required in the interest of the

insurance industry. In such instances, it will be done in compliance with the PDPA.

We may also disclose your Personal Data where such disclosure is required under the law, court orders or pursuant to guidelines issued by

regulatory or other relevant authorities, if we reasonably believe that we have a lawful right to disclose your Personal Data to any third party or that

we would have had your consent for such disclosure if you had known of the same, and/or if the disclosure is in the public interest.

Your personal data may also be transferred to our related companies and third party providers, which may be located outside Malaysia for the

Purpose. In the event that we use external service providers, specic security and condentiality safeguards have been put in place to ensure your

privacy rights remain unaected.

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How to Access, Correct, Update or Limit the Processing of Your Personal Data with Chubb

You may make inquiries, complaints or request for access to or correction of your personal data or limit the processing of your personal data at any

time hereafter by submitting such request to us at:

Chubb Insurance Malaysia Berhad (9827A)

Manager, Customer Service Unit

Wisma Chubb,

38 Jalan Sultan Ismail,

50250 Kuala Lumpur, Malaysia.

TF 1800883226

E Inquiries.MY@chubb.com

About Chubb in Malaysia

Chubb is the world’s largest publicly traded property and casualty insurer. With operations in 54 countries, Chubb provides commercial and

personal property and casualty insurance, personal accident and supplemental health insurance, reinsurance and life insurance to a diverse

group of clients. As an underwriting company, we assess, assume and manage risk with insight and discipline. We service and pay our claims

fairly and promptly. The company is also dened by its extensive product and service oerings, broad distribution capabilities, exceptional

nancial strength and local operations globally. Parent company Chubb Limited is listed on the New York Stock Exchange (NYSE: CB) and

is a component of the S&P 500 index. Chubb maintains executive oces in Zurich, New York, London and other locations, and employs

approximately 31,000 people worldwide.

Chubb’s operation in Malaysia (Chubb Insurance Malaysia Berhad) provides a comprehensive range of general insurance solutions for large

corporates, small and medium-sized businesses, as well as individuals through a multitude of distribution channels. With a strong underwriting

culture, the company oers responsive service and market leadership built on nancial strength. Chubb in Malaysia has a network of 23

branches and more than 2,500 agents.

Notice

This form is furnished by Chubb as a matter of goodwill, and Chubb accepts no responsibility for the validity of this form.

Chubb Insurance Malaysia Berhad

(formerly known as ACE Jerneh Insurance Berhad) (9827A)

(Licensed under the Financial Services Act 2013 and regulated by Bank Negara Malaysia)

Wisma Chubb

38 Jalan Sultan Ismail

50250 Kuala Lumpur

Malaysia

O +6 03 2058 3000

F +6 03 2058 3333

www.chubb.com/my

are protected trademarks of Chubb.

Published S27/04/17/V1