Untitled Document

Personal Information

Policy Number
First Name		Last Name
Landline		Mobile
Email
D.O.B
Gender
Civil Status

Physical Address and Mailing address Occupation
Please specify Claims made by you over the last Five years

When would you like your insurance coverage to begin?

Month

Date

Year

Insurance History (Last five years): Name of Insurer Reasons for cancellation (If any)

SECTION 1

(A) DWELLING BUILDING DETAILS

A.1.

House/Plot #	Street Name	Type of Construction	Value	Occupancy

A.2. Please specify security arrangements at each location

(B) PERSONAL PROPERTY:

B.1. Total value of Contents in the residence (Excluding items under C)

(C) ALL RISKS SECTION

C.1.Specify details of Items you would like to Insure on "All Risks" basis:

Description of item	Serial #	Value

In case you have more items to insure under this section you may please use the text box hereunder

SECTION 2

(A) PERSONAL LIABILITY A.1. Please state the required personal liability limit you would like to have :

(B) VOLUNTARY - MEDICAL PAYMENTS: B.1. Please state the medical payments limit you would like to have

DECLARATION
I/We hereby declare that all the above statements and particulars which
I/we have read and checked are true Correct and Complete and contains
information to me/us affecting the proposed insurance and trust this
and any other statement made by me/us to PROFESSIONAL INSURANCE
CORPORATION LIMITED shall be THE BASIS OF AND INCORPORATION IN THE
CONTRACT BETWEEN ME/US AND THE COMPANY. I HAVE UNDERSTOOD THAT IN CASE
OF PARTIAL LOSS, IF SUM INSURED FALLS SHORT OF MARKET VALUE ON THE DATE
LOSS, I HAVE TO BEAR THE PROPORTION OF SUCH SHORT FALL TO THE MARKET
VALUE.
I/WE FURTHER AGREE TO ACCEPT INSURANCE ON THE TERMS AND CONDITIONS SET
FORTH IN THE COMPANY´S POLICY.
I/WE FURTHER AGREE TO ACCEPT INSURANCE ON THE TERMS AND CONDITIONS SET
FORTH IN THE COMPANY´S POLICY
(If signing for a company indicates authority and state the name of the
Company/Agency).
IMPORTANT NOTICE
This Proposal will form the basis of a legally contract and absolute
truth and accuracy in answering the questions is essential. Before
signing the SPECIAL DECLARATION ensure that ALL questions are answered
correctly. Failure to comply may result in the cancellation of cover
and/or the reputation of any claim
If answers are completed by any agent the Proposer must sign and the
answers will be deemed to be the proposer ’s answers. Any other person
signing will be deemed to have signed as the agent of the proposer with
the full knowledge and consent of the proposer.
The policy includes
Hiring, carriage of passengers for hire or carriage of fare paying
passengers racing speed or other contests rallies trials carriage of
explosive of carriage of any load or passengers exceeding with the
capacity for which it is constructed or licensed to carry or use for
any purpose in connection with the motor trade.
The indemnity to the insured in connection with any vehicle shall
operate write such vehicle is in the custody or control of a member of
the motor trade for the purpose of its overhaul upkeep of repair.
Date:                    signature