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answer all the questions fully |
Full Name
Address of property to be insured: (incl. Block and Parcel#)
Location:
On water
On land
E-mail:
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Phone
Number Home:
Phone
Number Work
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| 1.
Construction of property to be insured? |
Concrete
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wood |
Other
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2. Have any hurricane and/or earthquake resistant features been incorporated
in your home's construction? |
Shutters |
Straps/Clips |
None |
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3. Is the home occupied continually by yourself or others? |
Yes |
No |
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4. Are there any security measures installed which are designed
to reduce the possibility of theft? |
Yes |
No |
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5. With regard to any of the risks to be covered, has any person(s)
to be insured:
a) Sustained any loss, damage or liability in the last 5 years? |
Yes |
No |
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b) Ever had a proposal for insurance declined, renewal refused, cover
cancelled, or special conditions imposed by any insurer? |
Yes |
No |
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6. Do you have any policy which presently covers any of the property
for which insurance is now proposed? |
Yes |
No |
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7. Which of the following describes your home: |
Detached Home |
Apartment |
Townhouse |
Other:
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8. What is the approximate age of your home? |
Years |
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9. What is the approximate floor area? (including garages, covered
patios etc.) |
Square Feet |
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10. Is the property in a good state of repair: |
Yes |
No |
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11. Name and address of Mortagage Interest:
Property and/or Liability to be insured
1. Buildings
Your home (including outbuildings), its landlord's fixtures and fittings,
patios, terraces, footpaths, hard courts, walks, gates & fences:
$ Sum Insured
Swimming pool(s):
$ Sum Insured
Sea walls, docks, jetties:*
$ Sum Insured
Satellite dished $
$ Sum Insured
*If cover is required for sea walls, docks, jetties, please complete the
following:
Date constructed
$ Sum Insured
Materials used
2. Contents
Household goods and personal effects (including VALUABLES & ELECTONIC
EQUIPMENT), fixtures, fittings and interior decorations belonging to you
(or for which you are responsible), or belonging to your family or domestic
employees permanently residing with you.
$
VALUABLES comprise stamp, coin or medal collections, curios, pictures,
other works of art, articles of gold, silver or other precious metal,
jewellery or fur. If the amount of your VALUABLES exceeds 1/3 of the contents
sum insured, please state the total amount of such VALUABLES:
$
$ Also please list below any item of valuables which exceeds the single
item limit of 5% of the contents sum insured or $2,500 whichever is less,
together with its value. Receipts or valuations may be required
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Item
Item
Item
Item
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$ Value
$ Value
$ Value
$ Value |
3. Liability
A. Your legal liability to domestic employees. This cover is included
up to a limit of $250,000.
B. Your legal liability as owner and/or occupier and in a personal capacity.
This cover is included up to a limit of $250,000.
4. Accidental loss or damage (all risks)
a) Valuables and Personal Effects
These include VALUABLES and such items as camera equipment, binoculars,
watches, most sports equipment, etc. Each item to be covered must be listed
below together with its value which must be verified by receipts |
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Do you require this cover?
YES
(If Yes, we will contact you by phone for specifics)
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NO |
b)
Electronic Equipment
A wide range of such equipment can be covered including audio and video
equipment, home computers, receiving aerials, etc. from loss/damage/destruction
by any cause not excluded. |
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Do you require this cover?
YES
(If Yes, we will contact you by phone for specifics)
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NO
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