PROPOSAL FOR HOME INSURANCE
Please answer all questions. Benefits under the policy may not be payable in the event of non-disclosure or misrepresentation of material facts. If you are in doubt as to whether any fact is material please disclose same. Tick boxes (√) where appropriate.
Token Number          
If you have already filled Form 1 and did not submit details, enter the token number you received.

 
1 * Full Name
  (Rev./ Mr./ Mrs./   Miss./ Dr.)
:
* NIC NO. :
2 * Postal Address :
 
* Phone No. :
   Fax No. :
* E-mail :
3 Profession / Occupation :
4 * Address of the Property to be insured :
5 * Home Building :
 Owner Occupied
 Tenant Occupied
 Permanent Residence
 Alternative Residence / Second
6 Home Mortgagee (if any) :
7 * Period of
  Insurance
:
From :
  To :
               
    

8. General Information
* 8.1. Construction of the house                   :
Walls:
Roof:
* 8.2. Age of the Building (Approximately)   :
Years:
* 8.3. Is any part of the building occupied other than as a   residence?
  If "Yes" give details
Yes
No
* 8.4. Will you leave your home unoccupied during the day or night or for a period of time?
   If "Yes" give details
Yes
No
* 8.5. Are drainage facilities in the premises and in the neighborhood adequate?
Yes
No
* 8.6. Give particulars of cyclone/storm/tempest and flood damage, which has occurred in
   the area during past 5 years


   8.7 Are there any tall trees, antennas, masts etc. in close proximity? If so, describe,
   indicating distance(s)


Yes
No
* 9. Insurance / Loss History
* 9.1. Suffered loss from any of the perils proposed to insure against?
   If "Yes" give details
Yes
No
* 9.2. Have you ever been previously insured with another insurer?
   If "Yes" give details
Yes
No
* 9.3. Have you ever been refused for purchasing personal property insurance?
   If "Yes" please state the name of the Insurance Company and reason for refusal?
Yes
No
10. Please indicate your desired cover
10.1 Property

Sum to be Insured
* 10.1. a.
* • Buildings, fixtures and fittings (if you are the owner)
Rs.
* • Boundary wall, gates and fences
Rs.
* • Other domestic structures
Rs.
* 10.1.b. Landlord's fixtures and fittings for which you are responsible
             (if you are the tenant) and tenant's improvements
Rs.
* 10.1.c. Contents in the home
* • Furniture, House-hold items & Personal effects. (not easily movable)
Rs.
* • Furniture, House-hold items & Personal effects. (easily movable)
Rs.
* • Other items.
    
Rs.
Basis:
Replacement
Indemnity
11.Optional Extensions


11.1. a. Electrical, Fire & Lightning Damage to Electrical appliances & installations.
            • Please give the following details
Type of Equipment
Make
Year of Make
Serial No
Sums to be Insured (Rs.)
Riot, Strike and Terrorism Covers
Basic Policy does not cover against cover Riot, Strike, Malicious Damage and Terrorism
11.1. b. Do you require cover against Riot, Strike &
              Malicious Damage?
Yes
No
11.1. c. Do you require cover against Terrorism?
Yes
No
11.1.d. Personal Accident (for named persons) - Max.Rs.1, 000,000 per adult.
Name
Date of Birth
NIC No.
Capital Sum Insured (Rs.)
11.1. e. Workmen’s Compensation for Domestic Employees (Covers as per prevailing Workmen’s Compensation ACT and subsequent amendments)
Category (nature of duties)
Number
Estimated Annual Wages (Rs.)
Please check your answers carefully before signing the declaration below.
Declaration

I / We want to effect the insurance specified here and I / We
  • declare that all the answers given in this Proposal are in every respect true and correct.
  • agree that this Proposal and Declaration shall be basis of the Contract of Insurance between me / us and People’s Insurance Limited.
  • understand this application will be subject to the approval of People’s Insurance Limited and the premium fully paid and received by the Company before cover is effected.
 
Proposer's Signature
Date:
I hereby agree that the entered details are correct