| QUESTIONS TO BE ANSWERED BY THE PROPOSER
PERSONALLY |
| 1 (a) State
whether the Residence is a dwelling house |
Dwelling House
flat
or service flat
|
| (b) If a flat, is it self contained (i.e a flat to which access is obtained only by a separate locked entrance)? |
YES
NO
|
| 2 (a) Is any portion of the residence let-off as Apartment or to paying guests? |
YES
NO
|
| (b) Is any portion of the out-building let-off to other tenants |
YES
NO
|
| (c) Is any portion of the building occupied otherwise than for domestic purpose? |
YES
NO
if so, please give full particulars?
|
| 3 (a) Is any portion of the external walls of the residence constructed other than of brick, stone or concrete? |
|
| (b) Is any portion of the roof of the
premises constructed other than of slate, tiles, concrete,
metal or asbestos? If so, in
either case, please give full particulars |
|
| 4 To what extent
will the premises be left unoccupied? |
|
| 5 Are all the building in good repair and will they be so maintained? |
YES
NO
|
| 6 Does the total
amount of platinum, Gold and Silver Articles, Jewellery and Furs exceed
1/3 of the full value of the content? |
YES
NO
If so, state total value of such articles
|
|
| 7 Have all
"All Risks Policy" covering valuable? |
YES
NO
If
so, state Company
|
| 8 Are you
now or have been insured against any of the perils specified in the
Prospectus? |
YES
NO
|
| 9 Have you
ever sustained loss through any of the perils specified in this
Prospectus? |
YES
NO
|
| 10 Has any
Company or Underwriter decline any proposal for Insurance by you or
cancelled or declined to continue any Insurance for you, either at this at
premises or elsewhere? |
YES
NO
If so, please give full
particulars
|
| 11 Is this Proposal in
lieu with any existing policies with this or any other Company? |
YES
NO
If so, please quote company and
Policy Numbers
|
|
DECLARATION BY PROPOSER: I hereby declare
that the above particulars and statement are true, correct and complete
and contain all information known to me affection the risk to be insured
and that this any other written statement made by me or my behalf for the
purpose of the Insurance shall be the basis of, and incorporated in the
Contract between me and Goldlink Insurance Company Limited and shall be
promissory. I further agree to accept Insurance on the term's and
condition set forth in the Company's
policy |
