"AN INSURANCE AGENT WHO ASSISTS AN APPLICANT TO
COMPLETE AN APPLICATION OR PROPOSAL FORM
FOR INSURANCE SHALL BE DEEMED
TO HAVE DONE SO AS THE AGENT OF THE
APPLICANT"
1. Name of Proposer
2. Telephone
3. Address of Proposer
4. Email Address
5. Occupation, Trade or Business
6. Address of premises containing the
property to be insured
7. State whether factory, warehouse, shop etc
8(a) Are the premises occupied at night? YES
NO
(b) Is a watchman or caretaker employed? YES
NO
9. State how long you have occupied the premises
Are you the sole occupier? YES
NO
10. Is burglary alarm system installed? YES
NO
If so, State type
11. Are all or any of the valuables secured in a
thief-resisting safe
when the premises are closed? YES
NO
If so, state the make of
safe, cost and date of purchase
12. Give full details of any loss or damage
by the thief which you have sustained or any attempted threat
13. If the premises have been entered, state steps
taken to prevent further entry
15.Has any insurer ever
(a) declined
your proposal? YES
NO
(b) refused to renew or cancelled your policy
YES
NO
(c) increased your
rate of premium? YES
NO
(d) imposed special conditions? YES
NO
16. Do you keep detailed records of stock
received and sold? YES
NO
17. Could the exact amount of this loss be
ascertained from these records YES
NO
18. When can the premises be inspected by our
Surveyor?
Property to be insured
Full Value of Property
Value to be insured
1.
STOCK-IN-TRADE, inclusive of goods in
trust or on commission for which the proposer is responsible
(excluding gold and silver articles jewellery and furs)
2.
TRADE FIXTURES, FITTINGS, UTENSILS, PLANT AND
MACHINERY
3.
OFFICE FURNITURE, FIXTURES, FITTINGS,
UTENSILS, PRINTED BOOKS AND STATIONERY
