Residence Address:

Is there a trade or manufacture carried on the premises? if yes give details.
Is your residence insured with another company?
Has your insurer declined to accept or renew the insurance on your residence? If yes give details.

Sum 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.

I Declare That The Statement In This Proposal Whether In My Own Handwriting Or Not, Are True And I Agree That This Declaration Shall Be The Basis Of The Proposed Contract Of Insurance. I Also Undertake To Notify The Company Of Any Change In The Information Mentioned Above.