Householder Proposal Form Name All questions must be answered completely The liability of the company does not commence until the proposal has been accepted and the premium paid. Name of Proposer * Proffession/Occupation * lf Proposer is married state occupation of spouse Postal Address Property situate Title Mr Mrs Miss Work No. * Home No. Mobile No. Email * Is this proposal to replace an existing policy with NETHERLANDS INSURANCE COMPANY? Yes No Do you hold any other policies (e.g. Business, Motor) with NETHERLANDS INSURANCE COMPANY? Yes No Do you hold any other policies for any of the risks now proposed? Yes No Please state the name of the insurer Has any insurer in respect of the risks for which you now propose: Decline to insure you? Yes No Cancelled or refused to renew your insurance? Yes No Imposed any special terms or premium? Yes No Have you ever sustained a loss from any of the perils for which you now propose? Yes No Are you in a position to meet all your financial commitments at present? Yes No What is the age of the building which is to be insured or in which your contents are housed? Of what materials Is the building constructed? External Walls: Roof: Floor: Is the building in good state of repair and will it be so maintained? Yes No Is the building used for residential purposes only? Yes No Is the distance from the nearest building less than 20 feet ( 6 meters)? Yes No Is the vicinity of the building subject to flooding or specially exposed to lossby any of the perils to be Insured against? Yes No Period of insurance From To I desire to effect an Insurance with Netherlands Insurance Company (WI ) L1m1ted and do hereby declare that the statements above and overleaf are true, that I have withheld no material information; that the foregoing sums to be insured are to the best of my knowledge and belief not less than the full value of the property to be insured on the basis proposed and will be so maintained I agree that this Proposal and Declaration shall be the basis of the contract to be made between me and the Company I desire to effect an Insurance with Netherlands Insurance Company (WI ) Limited and do hereby declare that the statements above and overleaf are true, that I have withheld no material information; that the foregoing sums to be insured are to the best of my knowledge and belief not less than the full value of the property to be insured on the basis proposed and will be so maintained I agree that this Proposal and Declaration shall be the basis of the contract to be made between me and the Company Name of Proposer Date Complete this section if you are insuring your building Is your building a completely detached private dwelling house? a portion of a building (townhouse. fiat)? a block of flats? What is the height of the building in storeys? Is lhe building mortgaged? Yes No What is the approximate superficial area of the building? square feet/meters Do you wish to insure on the Reinstatement Basis? Yes No Section 1 – Building Sum to be insured On Building (including walls gates and fences) Building On retaining walls Retaining walls On swimming pool Swimming pool On Central Air-Conditioning Equipment Air conditioning equipment Complete this section if you are insuring your contents Is your dwelling a private dwelling house? a self-contained flat with separate entrance exclusively under your control? rooms, not being a self-contained flat? Is your Dwelling occupied solely by you and your family and servants? Yes No If you are renting the dwelling, does your landlord provide for your use Full furniture Some furniture No furniture What protection Is there against loss by burglary Will the dwelling be left unoccupied for more than 120 days in aggregate during any one period of insurance? Yes No Section 2 – Content (do not include items to be insured by section 3) Sum to be insured On the whole contents (excluding any items specifically Insured below) On Computer, Stereo Equipment, Television, Video recorders, and the like (Please supply details) On Jewellery while in your dwelling (please provide valuations and/or receipts) whole contents stereo equipment jewellery Complete this section if you are insuring items against "All Risks" Will any of the items be used by anyone except yourself or a member of your family living with you? Yes No At what premises is the property usually kept overnight? SECTION 3 "All Risks" (Please attach a list or lists marked (a) or (b) as appropriate and valuations/receipts) Sum to be Insured On the specific items anywhere in (a) Grenada and dep. or (b) the World All Risk Sum Total of Sections 1-3 total sum Total:
