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DOMESTIC INSURANCE

DETAILS OF PROPOSER

 
Name: Postal address:
Tel. No Email address:

Occupation

 
COVER DETAILS  
Construction type 1) Roof 2) Wall
Location:    
Sum insured: 1) Buildings 2) Burglary:
Cover required - Please tick as appropriate: Fire Burglary All risks

 

  

Number of domestic servants:

Public/personal liability

Financial interest, State either bank or self

Security in place

OTHER POLICIES

 
Any other policy insuring this property? If so state insurer and policy number

INSURANCE HISTORY

 

Has any insurer -:

Declined to insure you?
Required special terms to insure you?
Cancelled or declined to renew your insurance?
Increased premium at renewal?

CLAIMS HISTORY

 
Have you claimed in the past? If so give details

DECLARATION

I do hereby declare that the above answers are true and I have not withheld any material information regarding this proposal.

SIGNATURE __________________

 

DATE: _____/_____/_____

Click to download Data request form – Domestic Insurance
Data request form –Domestic Insurance
 
 
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