The Applicant

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:

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

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
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:

Is there-an Electric Generator? No Yes
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

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.