Fire Proposal POLICY NO:PREMIUM:RATE:Name of Proposer: (In Full) First Last (At an Unlimited Company or Partnership Include full names of all partners):Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Trade Profession or Occupation:Telephone No:CellHomwWorkEmail Situation of Property to be Insured:Insurance RequireFromToMortgagee:PROPERTY TO BE INSUREDWhere insurance on Buildings is required a separate sum insured must be given for each separate building, and for insurance of Contents a separate sum insured must be given for the Contents contained in each separate building (if more than one building continue on separate sheet). Cover: Fire, Hurricane, EarthquakeBuilding (as described on opposite page):*Contents (Furniture, fixtures, fittings):Stock or Materials in Trade, the property of the Proposer or held by him in Trust or on commission for which he is responsible:Machinery, Planter Equipment and other Contents:Month’s Rent (i.e. “Rent Receivable” “Rent Payable” or, as in case of Tenant Owners “Rental Value’ – cross out which are not applicable):Other Property as Follows:TOTAL:Do the above sums represent the full value of the property to be insured?*NOTE Unless expressly mentioned the Insurance will not cover: (I) bullion or unseat precious stones. (II) any curiosity or work of art for an amount exceeding (III) manuscripts, plans, drawings or designs, patterns, models or moulds. (IV) securities, obligations or documents of any kind, stamps, coined or paper money, cheques, books of account or other business books. (V) explosives 1. Are the premises in your sole occupation? If not, please give particulars of the business or trades carried on.2. How long have you occupied these premises? If only recently give previous address.3. Have you been insured hitherto? If so, state name of any and Number of Policy.4. Have you or, if appropriate, any of the partners, ever had a proposal for insurance of any kind, or renewal of a policy declined or a policy cancelled? If so, give particulars5. Has a Fire occurred in or on any premises wholly or partially occupied by you or any of your partners if any? If so, give details6. Give particulars of any policies in force with this or other Companies covering any of the property to be insured.7. Give the following particulars of any building within 10 feet of the property to be insured: (a) construction(b) height approx(c) occupationd. i. If adjoining, whether communicating with proposer’s premisesd. ii. if separated, the distance of separation(Note: The above information can be linked with sketch plan)Give the following particulars of each separate building to be insured or in which the property to be insured is situated (if more than one building continue on separate sheet)8. Construction of External Walls9. Construction of Roof10. Construction of Floors11. Construction of Internal Walls12. Construction of Windows13. a. Number of Floors (including ground floor)13. b. Is building bolted to concrete foundation?14. Any ceilings, partitions or other linings of Calico, Canvas Rush?15. If Storage Warehouse:- (a) Nature of goods stored:15. (b) Proportion of hazardous goods16. If Manufacturing Premises:-(a) Power usedBrief Details of Process17. Form of LightingElectricityOthers18. Portable Fire Extinguishers, if any.Note: Where premises consist of two or more buildings a sketch plan should be given. DECLARATION: I/We desire to effect with the Company an insurance in the terms of the policy used for this class of business and I/We declare that the above statements and particulars are correct. I/We agree that this proposal shall be the basis of the contract between me/us and the Company. Date Date Format: MM slash DD slash YYYY Signature of Proposer:The Insurance will not be in force until the proposal has been accepted by the Company and the premium paid.