Monday, January 3, 2011


To be completed by you the ‘Proposed Insured’ Proposed Insured
“You, your and yours” where used in this Proposal means the Proposed Insured and, If more than one, each of them
Please print your answers as clearly as possible
Your Previous Insurance History. These questions apply to you either alone or jointly with any other party or, if you are a corporation, the corporation or any of its directors.
1 .Has any insurer declined an application from You, or cancelled or refused to renew a policy of Yours, required special terms to insure You, or declined or refused a claim? Yes . No .
2. Have you sustained any loss or damage to property in the last 5 year? Yes . No .
3. Have you had any claim made against you for property damage or personal injury in the last 5 Years? Yes . No .
4. Have You, or any person who will receive insurance protection under the proposed Policy, been charged with or convicted of, any criminal offences in the past 10 years? Yes . No .
5. During the last two year have You or any other person to whom cover extends under this policy received any threats to life or property (private or business)? Yes . No .
6. Are there any other relevant facts relating to the risk to be insured which You should disclose to Us, to enable a true assessment of Your insurance Application? Yes . No .
7. Is any portion of the property to be insured in a state of disrepair or poor condition? Yes . No .
If you answered Yes to any of the above please give details. Please attach full details on a separate sheet of paper if not sufficient space on this form:

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