] HOME PROPOSAL FORM Policy Period From: To: DETAILS Name of Proposer* Email* Address of the Proposer* Address of the Property to be Insured* Telephone No.* Mobile No. Date of Birth Yours: Your Partner: ID Card No. Yours: Your Partner: Business or Occupation Yours: Your Partner: GENERAL DETAILS Please tick the appropriate box. 1. Have you or any of the members of your family normally residing with you A) Suffered any loss, damage or liability from any cause within the last five years? Yes No B) Had a proposal declined, a renewal refused, cover terminated, special terms or conditions imposed by any insurer? Yes No C) Being convicted, or charged but not yet tried , for any offence other than driving offences? Yes No 2. Are the buildings situated at the address of the property to be insured A) Type of Property: Flat Maisonette Bungalow House B) Left without an adult resident for more than 90 days in a row? Yes No C) In a good state of repair and will be so maintained? Yes No D) Built of brick, stone or concrete and roofed with slate, tiles, concrete, asphalt, metal sheets or slabs composed entirely of incombustible mineral ingredients? Yes No E) occupied by you and your family and used only as a private residence? Yes No 3. Are you or have you previously been insured for your Home Buildings or Contents? Yes If YES please give details Name of Insurer: No Policy Number: 4. If your premises are protected by an intruder alarm, please tick the relevant boxes and answer the following A) Type of Alarm B) Name of the installing firm C) The date the system was installed D) Is the alarm subject to an annual maintenance contract? Yes No E) Do you wish to apply for the intruder alarm discount? Yes No SECTION 1: BUILDINGS Please answer the following questions if the buildings are to be insured and state the sum to be insured. 1. What is the required Sum Insured based on the rebuilding cost as new? 2. Would you like to apply for the Enhanced Cover to extend accidental damage to your buildings? Yes No 3. Please give the year the property was built (approximate date if not known) 4. Please state the name and address of any Lessee or Mortgagee whose interest in the Building is to be named in the Policy SECTION 2: CONTENTS 1. What is the current required Sum Insured based on full replacement value as new of your Contents situated at the Address of the Property to be Insured? 2. Would you like to apply for the Enhanced Cover to extend accidental damage to your Contents? Yes No 3. a) What is the current total amount of valuables* included in the Contents sum insured in (1) above? *Valuables means stamp, coin or medal collections, antiques (not including furniture), collectibles, pictures, paintings and other works of art, items of gold, platinum, silver, or other precious metals, jewellery, watches and furs. No one single valuable is worth more than Lm 1000 unless specially insured as a separate item. b) Specify all single valuable items exceeding Lm 1000 Description Value i) ii) iii) iv) v) (please attach recent and updated valuations/receipts of each item and a separate sheet if more space is required) c). Do you want to cover any single item of audio, audio-visual and home computer and entertainment equipment for accidental damage which exceeds the limit of Lm1000? Yes No 4. Would you like to extend the policy limit on Pedal Cycles and Sports Equipment cover? If yes, please provide details: Yes No If YES please give details Value SECTION 3: PERSONAL BELONGINGS INCLUDING VALUABLES ITEMS 1. Would you like to cover unspecified personal belongings including valuables up to Lm300? (limit any one article Lm 75) Yes No 2. If you require cover for specified valuables please specify each item separately under this section Description Geographical Area Value i) ii) iii) iv) v) (please attach recent and updated valuations/receipts of each item and a separate sheet if more space is required) OTHER INFORMATION Please provide any other information which you think the company should be aware of and which could affect the judgement of this proposal. All information submitted will be processed in accordance to the Data Protection Policy of the Company. DECLARATION Please read, sign and date the following 1. I/We agree that the proposal shall be incorporated in and shall form the basis of the contract between me/us and Middlesea Insurance p.l.c. (the Company) and I/We further agree that I/We have disclosed all Material Facts* and to accept the Company’s standard form of policy for this type of insurance. * Material Facts are those facts which are likely to influence underwriters in the acceptance or assessment of this proposal and it is essential that you disclose of them. If you are in doubt about whether a fact is material then for your own protection you should disclose it since failure to do so could invalidate your policy. 2. I/We consent to the seeking of the information from other Insurers, their Agents and Insurance Associations to check the answers I/We have provided and I/We authorise the giving of such information for such purposes. Confirm you have read and agree to the data protection policy
Please tick the appropriate box.
*Valuables means stamp, coin or medal collections, antiques (not including furniture), collectibles, pictures, paintings and other works of art, items of gold, platinum, silver, or other precious metals, jewellery, watches and furs. No one single valuable is worth more than Lm 1000 unless specially insured as a separate item.
b) Specify all single valuable items exceeding Lm 1000
(please attach recent and updated valuations/receipts of each item and a separate sheet if more space is required)
DECLARATION Please read, sign and date the following
1. I/We agree that the proposal shall be incorporated in and shall form the basis of the contract between me/us and Middlesea Insurance p.l.c. (the Company) and I/We further agree that I/We have disclosed all Material Facts* and to accept the Company’s standard form of policy for this type of insurance.
* Material Facts are those facts which are likely to influence underwriters in the acceptance or assessment of this proposal and it is essential that you disclose of them. If you are in doubt about whether a fact is material then for your own protection you should disclose it since failure to do so could invalidate your policy.
2. I/We consent to the seeking of the information from other Insurers, their Agents and Insurance Associations to check the answers I/We have provided and I/We authorise the giving of such information for such purposes.
