Untitled Document

Online Home Insurance Proposal

The questions on this form and any other questions which we specifically ask, relate to facts considered material to underwriting the insurance. If you answer them fully and honestly you will be considered to have fulfilled your duty to disclose material facts. Failure to do so may invalidate your insurance. A copy of the completed proposal form will be supplied on request, but you should keep a record (including copies of letters) of all information supplied to us for the purposes of entering into this contract. A specimen policy is available on request.

The Proposer

Title	First Name
Initials	Last Name
Address of property to be insured


Correspondence Address (if different from above)

Date To Begin Insurance Cannot be before the proposal is accepted by the company

Home Telephone

Work Telephone

Email Address

Occupation

Your Home

Is your home:
	Occupied only by you (by "you", we mean your spouse, children and other relatives whop normally reside with you):	Yes	No
	If No - How many tenants:
	Do you live on the on the premises	Yes	No
	Used for any business or professional purpose:	Yes	No
	A weekend or holiday home:	Yes	No
	Normally unoccupied by adults for more than 4 hours on work days	Yes	No
	Left unoccupied for more than 2 months in a year:	Yes	No
	Protected by a burglar alarm system which includes at least one external bell:	Yes	No
	Protected by keyed mortice deadlocks on all external doors and can all external windows be secured from within:	Yes	No
	Protected by security grilles, bars or screens on all windows:	Yes	No
	In a good state of repair and will be so maintained at all times:	Yes	No
	Do you intend to carry out work other than routine maintenance or decoration:	Yes	No
	On a site which has been free from flooding during the last 10 years	Yes	No
	Adjacent to any body of water - such as the sea, a lake or canal:	Yes	No
	Closer than 25 metres to any neighbouring property:	Yes	No
	Roofed with:
	i. Concrete:	Yes	No
	ii Stone, Metal, Asbestos, Cement Sheeting, asphalt, Shingles or any other incombustible aggregates:	Yes	No
	Built with:
	i. External walls of brick, stone, clay, concrete, metal/asbestos on a steel frame with floor of concrete or other incombustible aggregates	Yes	No
	ii. External walls partly (75%) of brick, stone clay, concrete/concrete nogging, metal/asbestos and partly timber on steel or timber framed:	Yes	No
	iii. External walls of greater than 60% wood:	Yes	No
	With regard to the sections of cover you are selecting, have you or any person normally residing with you at your present address or elsewhere:
	Sustained any loss, damage or liability during the last 5 years whether insured or not:	Yes	No
	Had any insurance declined or cancelled or declared void, or had any special conditioned imposed:	Yes	No
	Have you or any members of your family normally residing with you, or directors where the proposer is a limited company, ever been convicted of any offence other than a motoring offence:	Yes	No
	If you have chosen any of the shaded options, give details of your answer below:

Buildings

Do you require this cover: Yes No
If you require contents cover, please answer the questions below (do not include items you wish to cover under the Personal Possessions optional extension).
What is the full cost of rebuilding your home:
The home plus landlord's fixtures and fittings:		Swimming pools and tennis courts:
Patios, footpaths, walls (but not seawalls), gates, fences & driveways:		Docks, jetties, piers, seawalls, or similar waterside structures:
Other outbuildings:		Total:

What is the approximate area of your home in square metres:
Mortgagee or other interested parties:
Name:	Address:

Home Contents

Do you require this cover: Yes No
If you require contents cover, please answer the questions below (do not include items you wish to cover under the Personal Possessions optional extension).
Cover Required: Standard Standard Plus	Do you require Full Theft cover: Yes No
What is the replacement cost of your "high-risk" items (ie):
TV, Personal Computer, Audio & Video equipment:	Jewellery and Watches:
Clocks and articles of precious metal (other than jewellery):	Pictures, works of art, curios and collections:
Furs:	Photographic equipment:
Pedal cycles:	Total of high-risk items: (a)
	Total of other contents: (b)
	Total of (a) + (b) above:
If the replacement of any high-risk item exceeds EC$4,000 list items and values below:
Item Description		Value

Satellite Television Systems

Do you require this cover: Yes No
If yes, what is the replacement value of the equipment:
What is the Make & Model of the equipment:

Optional Extensions

In order to take any of the following extensions, you must have taken Home Contents Insurance

Personal Possessions (Cover on valuables, personal effects and clothing)

Cover Required: Yes No

Unspecified items up to EC$2,000 each
Sum insured ($6,000 min.)

Describe items worth more than EC$2,000 or particularly vulnerable items (ie, contact lenses, portable musical instruments, camping equipment):

Item Description

Value

Note: Valuations are required for items worth more than EC$4,000

Credit Cards (Limit EC$2,000) - Cover Required: Yes No

Accidental Death and permanent disability - Cover Required: Yes No

If yes, please give the details below for each person to be insured:

Name

D.O.B

Name

D.O.B

Are all persons to be insured in a good state of health and free from any physical or mental defect or infirmity:

Yes No

If no, please give details:

Liability

When you take out "Buildings" or "Home Contents" you are automatically covered for liability arising out of you being owner or occupier of your home or in a personal capacity. You can extend your policy to cover "Liability arising as an employer of domestic staff":

Do you require this cover: Yes No If 'yes', how many domestic staff do you employ:

DECLARATION

I declare that to the best of my knowledge and belief the statements made by me or on my behalf are true and complete. Please check this box to affirm