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PROPOSAL FOR "COMBINED HOUSE-OWNER AND HOUSE HOLDER" 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.

For Corporate Organisation Click Here.

	Surname *	Surname is required.
	First Name *	First Name is required.
	Middle Name
	Title	Please select an item.
	Full Postal / Contact Address
	Phone Number (s)
	GSM Number
	Fax Number(If available)
	E-mail Address *	Email is required.

	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

Note: The SUM TO BE INSURED must represent the FULL VALUE of the property being required to sign a declaration to that effect below. The insurance will be subject to average, which means that if at the time of loss or damage the sum insured is less than the full value of the property insured, the amount payabe is proportionally reduced.

THE BUILDING
The building of the private Dwelling House of Private Flat all the Domestic Offices,Stables,Garages and out-buildings used sole in connection therewith and on the same premises including Landlord's Fixture Fittings therein and the walls. Gates and Fences around and pertaining thereto.

Full address of premises of which the insurance is required*

Item 1	The buildings (except any part thereof specially insured Hereunder as seperate items)	1. N *
		2. N
		3. N
Item 2	Gate and fences ( if any )	N

	Total sum to be insured on Buildings	N
Note:- Any property to be insured under Contents should be excluded

THE CONTENTS Furniture,Household Goods and Personal Effects (except as after mentioned) the property of the Proposer or any member of the proposer's family normally residing with the proporser is legally responsible
Note 1: No one articles (Furniture, Household appliances, Radio and Television Sets, Piano and Organs excepted) will be deemed of greater value than five per cent of the total Sum insured on the said Contents unless article is specially declared as seperate item
Specify here any such articles of greater value than 5 percent(5%) of the Total Sum to be insured on the said Contents
Contents	Value
1.
2.
3.
4.

Note 2 : The amount of insurance on Platinum, Gold and Silver Articles, Jewellery,furs and works of Art is limited to 10% of the total Sum Insured on contents unless the value thereof is stated and additional premium paid. If the said value exceeds the proportion mentioned, please state the total value of such property below.

Note 3: The insurance on Contents does not cover any part of the structure or ceiling of the buildings,wall papers and the like, external television and radio antennae, aerials, aerial fittings,masts and towers nor any property to be insured under buildings, nor does it cover property more specifically insured under another policy or, unless specifically mentioned (Deeds, Bonds, Bill of Documents of any kind Cash, Currency notes,Manuscripts,Medals,Coins, Pedal Cycles, Motor Vehicles and Accessories or Livestock)
Period of insurance required from to both dates inclusive *
Total Value :
DECLARATION: I do hereby declare that the above answers are true and Ii have withheld no material information regarding this proposal, I agree that this declaration and the answers given above as any further proposal or Declaration or statement made in writing by me or any one acting on my behalf shall form the basis of the contract between me and LEADWAY ASSURANCE COMPANY LTD. I further agree to accept idemnity subject to the conditions as endorsed on the Company's Policy. I further undertake to inform the company of any material alteration to these facts whether occuring before or after completion of the contract of insurance.

THE BUILDINGS and their occupancy:

	Please state the nature of your residence (Check the description which apply)
(a)		Private Dwelling House
(b)		Self-contained flat with seperate entrance exclusively under your control and situated on the floor
(c)		Rooms not self contained and situated on the floor

Of what material is the dwelling constructed?
(a)	Walls
(b)	Roof

What is its height in stories?

Are there any out buildings and , if so , how are they constructed?
Walls
Roof

If any of the buildings to be insured is within 3.5m of any other buildings, state the distance, type of construction and use of such building

Are the buildings in a good state of repair and will they be so maintained?

(a) Is the dwelling occupied sole by:
(i) You and your family
(ii) Your family and house help(s)
(iii) Tenants
(iv) Paying Guests

(b) State the number of Tenants & paying guests in respect of iii & iv above

What are arrangements made on risk improvements such as:
(a)	For how many days ( whether consecutive or not ) is the dwelling likely to be left without an inhabitant during one year?
(b)	State as a number of days, the longest continuous period in any one year during which the dwelling is like to be left without an inhabitant
	Note: Attention is drawn to a provision in the policy that cover again Theft which will be suspended for any period or periods in excess of 30days during which the dwelling be left without an inhabitant therein unless specifically agreed to by the company.

Is there any profession business or trade carried on in the dwelling or in any portion of the premises of which the dwelling forms a part? if so give particulars

PREVIOUS INSURANCE AND LOSES

10.

Have you any other policies in force covering any of the perils to be insured against? If so, please give details thus
(a)	Type of insurance
(b)	Policy No
(c)	Name of Insurer

11.

Has any, insurer, in respect of any other perils to which the proposal applies:-
(a)	Declined to insure you?
(b)	Required special terms to insure you?
(c)	Cancelled or refused to renew your insurance?
(d)	Increased your premium on renewal?
	If so state reasons for such action

12.

Have the building and/or contents suffered damage by storm, tempest or flood during the past five years? If so, give particulars

13.

Have you ever sustained loss from any of the perils (other than those referred to in question 12 above ) to which the insurance is to apply? If so, give particulars

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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3437H

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