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UFA
Proposals
Fire Proposal
Personal Accident Proposal
Motor Insurance Proposal
Residential Fire Proposal
Term Life Proposal
Fire Proposal
The Applicant
Full Name
Phone N.
Region
Street
Building
Plot N.
Area
Owner or Tenant
Type of trade or manufacture carried on in the premises to be insured
Description of the building and the contents to be insured
A- Building:
Year of construction
Construction of walls
Construction of roof
How many floors
N. of floors to be insured
Are the rooms of the floor connecting or separated?
No
Yes
If they are separated state nature of separating walls
Use of the building:
Basement
Ground floor
Upper floors
B- Contents:
State type in details
Do the contents contain any inflammable or combustible products?
No
Yes
Type
Value
Quantity
Storage
Precautions
Are the electrical installations apparent or embedded?
Apparent
Embedded
Please state nature of used heating (electrical, Mazout, Gas or else)
Are the goods on palettes?
Yes
No
Height
what is their distance from ceiling or walls?
FIRE PROTECTION MEASURES:
Are there any fire extinguishers?
No
Yes
Sprinkler?
Manual
Automatic
Type
Quantity
Capacity
Are they regularly controlled?
No
Yes
Are there water tanks connected to hoses to extinguish fire?
No
Yes
The approximate distance of the nearest fire brigade?
Can a fire brigade reach the scene in a reasonable time?
Is there any automatic Fire Alarm System?
No
Yes
Are there persons (caretaker or watchman) regularly found in the location to be insured?
No
Yes
Supplementary Information
Boundaries:
Right
Front
Left
Rear
Is there-an Electric Generator?
No
Yes
Mark
Power
Location
Place of storage of the fuel tank connected to the generator
Do you keep regular book records showing goods value in the place to be insured?
No
Yes
Do you keep another copy of these books in a place other than the place to be insured?
No
Yes
Is the property now to be insured, partially or totally insured with any other insurance company?
No
Yes
Has this insurance ever been declined or cancelled by any other insurance company?
No
Yes
Have you ever sustained loss by fire?
No
Yes
Or water damage?
No
Yes
If yes, give details and amount of loss
Sums To Be Insured
Construction:
Machinery:
Merchandise & goods consisting of:
Neighbour's Recourse:
Office furniture:
Landlord Recourse:
Decoration, fixtures and fittings:
Total:
Additional Covers:
Lightning
Earthquake
Aircraft damage
Explosion
Impact damage
Damage due to storm, tempest or flood.
Damage due to bursting or overflowing of water tanks, apparatus or pipes.
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