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Home » Commercial Insurance » Quotes and Forms » Forms
  PROPOSAL FOR "BURGLARY BREAK IN" INSURANCE  
     
 

PLEASE NOTE: An agent who completes a Proposal Form does so as an agent of the proposer.

It is essential that every question with * be answered fully for proper processing of the form.

 
  Company Name * Company Name is required.  
  Contact Person * Contact Person is required.  
  Full Postal / Contact Address  
  Phone Number (s)  
  GSM Number  
  Fax Number(If available)  
  E-mail Address * Email address is required.Invalid format.  
         
  Anniversary Date  
  We can send alerts to you for renewal of your policy(ies). Please confirm how you would prefer to recieve your alert.
         

PROPERTY TO BE INSURED
1
a) Address of Premises in which property to be insured is contained
b) Description of Premises ( Shop, Warehouse, Factory etc)
2
To what extent are the Premises left unoccupied after business hours and during holidays.
3
Are stock books and sales books kept and posted promptly
4.
(a) Have you previously proposed for Burglary Insurance?
Are you now Insured?
(b) Has any insurer declined or required special terms to insure you or cancelled or refused to renew your insurance?
(c) Have you ever suffered a loss by Burglary or House breaking at these Premises or elsewhere?
If yes, please give the date and full details including the name of the insurer.
  DESCRIPTION OF PROPERTY
  SECTION I - PROPERTY PERTAINING TO THE PROPOSER'S TRADE OR BUSINESS AS DESCRIBED ABOVE:-
    TOTAL VALUE SUM TO BE INSURED
1. Stock in trade, the prperty of the Proposer
2 Similar property held by the proposer in trust or on commission, for the loss of which he is liable (If wines, Spirits or Tobacco and Cigarettes are included in the foregoing items, please state maximum value )
3 Trade Furniture, Fixtures, Fittings and utensils in the property of the Proposer
 

SECTION II PROPERTY BELONGING TO THE PROPOSER OR TO MEMBERS OF HIS
- FAMILY PERMANENTLY RESIDING WITH HIM, ALL IN PRIVATE USE
- AND CONTAINED IN THE RESIDENTIAL PORTION OF THE ABOVE MENTION PREMISES
1 Furniture, Household and Personal Effects (other than property described in the following items )
2. Valuable i.e furs, jewellery, gold, silver and platinum articles (other than article described below ) limited to one-half the amount of the preceding item unless extra premium paid
3 Articles to be speciallly insured: viz
  * Except for Furniture, Household Appliances, Organs, Piano, Gramophones, Radio and Televisions sets and articles specifically insured, the amount payable for any one article insured under section I is limited to 5 per cent of the total sums insured byt he items in section II. A seperate description and value must be given for each article to be specifically insured.    
  TOTAL SUM OF VALUE TO BE INSURED
  Date ddate
Please note that details of all items to be insured and their respective sums should be sent by fax or mail to our Corporate Office for further processing.
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