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PROPOSAL FOR "FIRE " 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.

(a)

Proposer

Agent

Individual

TITLE

Surname *

First Name *

Other Names

NEE (if a married woman)

(b)

Full Postal Address *
(to which all correspondence would be sent)

Tel. No. *

Permanent Address

Tel. No.

(c)

Occupation
(Pls give full details)

Fax. No.

E-mail Address *

(d)

Date of Birth

Day

Month

Year

(e)

Nationality
(if not Nigerian)

(f)

Marital Status

Married

Single

Divorced

Widow

PROPERTY TO BE INSURED

Full address of premises *

(a)	Do you have external walls constructed?
(b)	Do you have a roof constructed?

How many storeys in the premises?

(a)	What method of lighting do you use?
(b)	What method of heating do you use?

OCCUPATION OF PREMISES:
(a)	Is the whole building used for Residential purposes only?
(b)	Is any retail trade carried on?
(c)	What manufacturing processes or repair work (if any) are carried on within the premises?
(d)	Is any trade or business other than that of the proposer carried on within the premises? If so, give particulars.
(e)	What are the contents of the premises?
(f)	Are any goods to be insured of a hazardous nature such as those listed here.
(g)	Are there any hazardous goods located outside the building(s) and within 30 feet (10 meters) thereof? If so, give particulars.

ADJACENT PROPERTY

If the building is isolated. What is the distance between it and the nearest building? (in meters)

Describe the external walls and roofing of other adjoining buildings within 50 meters
Building to the right
Building to the left
Building in front
Building at the back

How are these adjacent buildings occupied

10.

If there is any building constructed partially or entirely of timber and roofed with leaves or thatch describe
distance
Occupation

FIRE EXTINGUISHING SERVICES

11.

What are arrangements made on risk improvements such as:
(a)	Type of extinguishing appliances secured
(b)	Hydrants
(c)	Hose Reels
(d)	Water Supply
(e)	Private Brigade
(f)	Distance between the building and the nearest Fire Brigade Station

12.

Are there any circumstances apart from those dealt with above which appear to increase the risk of loss or damage by any of the perils to be insured against? If so, give details.

13.

If there is any fire insurance in force on the same property, state:
(a)	Name of Insurer(s)
(b)	Amount of Insurance(s)

14.

Have you ever had a Proposal or Renewal of Insurance declined or a Policy cancelled or Renewal invited at an increased rate? If so, state name of Insurer and full particulars in each case

15.

Have you suffered loss by fire? If so, give particulars
(a)	Year
(b)	Policy No.
(c)	Amount Claimed (Naira)

16.

Do you
(a)	Take stock at least once a year?
(b)	Keep a proper set of account books?
(c)	Keep such books in a fire-proof safe? (If so, type of safe)
(d)	Remove such books to another building when the above premises are closed?

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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