GET A QUOTE NOW
  Fire Insurance Proposal Form

These proposal forms are not a proof of cover unless a written confirmation is given by our company.


The Insured
Policyholder *
Phone/Fax Number *
Profession
Status
 Owner         Tenant
Address
Description of the risk (Factory, Restaurant, Shop...)
Situation of the risk
Nature and date of construction
In which floor is the risk to be insured
Number of floors
Floor Use
Basements
Basements Use
Ground Floor
Upper Stories
Actual status of the building
 Good         Fair         Bad
Is there a generator? If yes, please state the following:
Mark
Power
Year of manufacture
Location
Neighbourhood description(nature of activity):
Covers
Basic covers: Fire, Lightning, Explosion, Aircraft Damage Sum Insured(US$)
Building:
Furniture and personal effects:
Fixture, decoration and fixed installations:
Equipments and machinery:
Stock:
Others:
Total:

Is there any dangerous or flammable product inside premises to be insured? If yes, please elaborate


Extensions Sum Insured(US$)
Impact of vehicle:
Earthquake:
Storm & Tempest:
Flood:
Accidental smoke:
Water Damage:
Rain Water Damage:
Deletion of Electrical Clause:
Strikes, Riots, Civil Commotion(SRCC):
Loss of use(please state period):
Loss of rent(please state period):
Business Interruption(Standing Charges &/or loss if profit)(please state period):
Removal of debris:
Architect's fees:
Others:

Liability Cover Sum Insured(US$)
Neighbour's and third parties recourse:
Landlord's recourse:
Tenant's Recourse:
Others:

Protection

Alarm or any other system
 Yes         No
Detection System
 Smoke         Fire         Gas         Heat
Fire and explosion fighting system
a- Water:Water tank in the premises
b- Extinguishers
 Yes         No
Type of Extinguishers(Powder,Water,CO2..) Number Capacity Location
Maintenance
 Yes         No        Periodicity: / Month
Automatic sprinkler system
 Yes         No
Maintenance
 Yes         No        Periodicity: / Month
General Information
Was the risk insured before? If yes, with which company
 Yes         No       
Loss history during 5 years(frequency,circumstances,paid amount)
What kind of measures were taken since?
I/We declare that the statements and particulars in this proposal are true, and it shall be the basis of any contract of insurance effected thereon.
We undertake to inform underwriters of any alteration to these facts occuring before completion of the contract of insurance.