Anjo Insurances
Homeowner's Proposal Form

Please provide the following contact information:

General Information
Full Name of Proposer
Postal Address
Mortgagee
Location of Property to be insured
Home Phone
Work Phone
E-mail
Proposer's I.D. No
Occupation
Period you require insurance
From
To
Construction Information
1. How is the Property Constructed?
		Main Building	Additional Buildings
A.	Exterior Walls
B.	Interior Walls
C.	Roof
D.	Floor
E.	Height in Storeys
2. Is the Property:
		Yes	No
A.	Showing any signs of Disrepair?
B.	Undergoing Major Repairs or Alterations?
Information on Location of Property
3. Is the Building:
		Yes	No
A.	In an area that has a history of Flooding, Subsidence or Landslip or Ground Heave?
B.	Along the Seacoast and within 200 feet of the High Water Level?
C.	Within 12 feet of any other building?
Information on Usage of Property
4. Is the Property:
		Yes	No
A.	A Private Dwelling or Apartment?
B.	A Condominium?
C.	Occupied By The Owner?
D.	Rented Out, Fully or Partially?
E.	Let as a Resort or Tourist Accommodation?
F.	Used for Business purposes?
G.	Likely to be unoccupied for more than 40 consecutive days?
H.	Used as a Weekend or Holiday home?
Historical Information
5. Have you been Insured before for any of the risks proposed?		Yes	No
A.	If Yes, who was your insurer?
		Yes	No
B.	Is there an existing Policy in force?
6. Have you or any member of your household ever:
		Yes	No
A.	Been convicted or charged with arson or any offence involving dishonesty of any kind such as fraud, robbery or theft?
B.	Sustained loss or damage by any of the risks or liabilities you now wish to insure
C.	Had any insurance refused or had any special terms and conditions imposed on you?
For all questions in Blue where you have ticked "Yes" (except for 4 (c) where you have ticked "No"), please enter details below
Sums to be Insured & Optional Extensions
Buildings
Sum Insured  - Main Building		$
Sum Insured  - Additional Buildings (If Applicable)		$
		Yes	No
Do you wish cover for Furniture in Transit?
Do you wish cover for Accidental Damage on Buildings?
Do you wish Subsidence/Landslip cover? (an engineer's report may be required)
If your buildings are within 200 feet of the Sea, do you wish cover for Flood caused by overflow of the sea?
Sum Insured - Waterside Structures (Engineers report required)		$
Contents: (Items requiring "all risks" type cover should be insured under the Personal Possessions section below
		Main Building	Additional Buildings
Sum Insured - Jewellery		$	$
Sum Insured - Stereo, TV, Video, Home Computers etc.		$	$
Sum Insured - Furniture, Fixtures & Fittings		$	$
Sum Insured - Personal Effects & Clothing		$	$
Total Sum Insured - Contents		$	$
		Yes	No
Do you wish cover for Accidental Damage on Contents?
Do you wish Subsidence/Landslip cover? (an engineer's report may be required)
If your buildings are within 200 feet of the Sea, do you wish cover for Flood caused by overflow of the sea?
Do you require Hurricane/Wind Storm Cover for a Satellite Dish?
If Yes, Specify the Sum Insured		$
Personal Possessions
		Worldwide Cover?
		Yes	No
Sum Insured - Unspecified Items	$
Sum Insured - Specified Items	$
Sum Insured - Sports Equipment	$
Sum Insured - Pedal Cycles (Limited to local jurisdiction)	$
I/We Declare that the statements and particulars given in this proposal are, to the best of my/our knowledge and belief, true and complete, that the sums insured will be maintained on a true and up to date basis and that this proposal shall form the basis of the contract between me/us and the UNITED INSURANCE COMPANY LIMITED.