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Applicant Details

Name
Applicant Address

Property to be insured

Address
Type of Lighting/Energy Supply
Is the whole building used for residential purposes only?
Is any retail trade going on?
Are any of the goods to be insured of a hazardous nature?
Are there any hazardous goods located outside the building (s)? And within 30ft thereof?
Do you take stock at least once a year?
Do you keep a proper set of accounts books?
Do you keep such books in a fire-proof safe?
Do you remove such books to another building when the above premises are closed?
Do you keep an online back up of such records?
For example, in the cloud
Any portable Fire Extinguisher?
Are there any adjoining or adjacent buildings?

Adjoining or Adjacent Buildings

Are adjacent buildings cut off by brick, stone or concrete walls, at least 9 inches thick, without openings, going up to and through the roof?
Are there any circumstances apart from those dealt with above which may appear to increase the risk of loss or damage by any of the perils to be insured against?

Amount to be insured which should be the full market value

N.B Boundary and Compound Walls, gates and fences are excluded from the insurance

Important

The sum insured under each item will be separately subject to AVERAGE. This means that if the actual value of the property is greater than the sum insured you will bear a rateable proportion of the loss accordingly.

Is there any fire insurance in force on the same property?
Which of the following do you require insurance against?

Additional Questions if additional perils insured against

Do the premises abut the road?
Are the premises built on the hillside?
Click or drag files to this area to upload. You can upload up to 5 files.
The photos should show all doorways, windows, or any other openings both in external and internal walls.

Declaration

I/We desire to effect an insurance in the terms of the usual Policy for Fire Insurance and declare that the above statements and particulars are true. I/We further declare that this proposal shall be the basis of the contract between me/us and the Insurer and that the amounts to be insured represent to the best of my/our knowledge and belief the full market value of the property stated.

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