| Full Name |
|
Address of Property Insured |
|
| Telephone numer(House)
|
|
Phone
number(Ofice) |
|
| Occupation or Bussiness |
|
Position |
|
| Period of Insurance: |
| From |
|
To |
|
| |
|
|
|
| General Information |
| Is Your House: |
| a)Built on Brick, stone or concrete and roofed
with slates,tiles,concrete,asbestors or metal? |
Yes
No
| |
| b)(i)In
a good state of repair and will it be so maintained at all
times? |
Yes
No
| |
| (ii)Do you intend to carry out work other than
routine maintenance or decoration? |
Yes
No
| |
| c)On a site which has been free from flooding
in the last ten years? |
Yes
No
| |
| d)Free from any sign of danger by landsliding
or subsidence? |
Yes
No
| |
| e)Occupy only by you?(By "You" we
mean you,your spouse,children,parent and other relatives who
normally reside with you) |
Yes
No
| |
| f)Used for any business or professional purposes? |
Yes
No
| |
| g)Left unoccupied for more than a month at a
time? |
Yes
No
| |
| With regards to this insurance have you, or
any person normally residing withyou at your present address
or elsewhere: |
| a)Sustained any loss,danger or liabillity under
the last five years whether insured or not? |
Yes
No
|
| b)Had any insurer declined,cancelled or declared
void insurance or impose special condition? |
Yes
No
|
| Have you or any member of your family normally
residing with you ever been convicted of any offence other
than driving offences? |
Yes
No
|
| If Yes give details |
|
| What is the full replacement cost of your: |
| a)Building(which means private dwelling house
or flat,domestic,offices,stable,garages and outbuildings,fixtures
and fittings)? |
|
| b)Gates,boundary walls,fences,drainage system,etc.? |
|
| c)Architects,surveyors,consultants,legal fees,etc.? |
|
| Name of mortgages/other interest party |
|
Address of mortgages/other interest party |
|
| Sum Insured: |
| 1)Building |
|
| 2)Contents |
|
| 3)Loss of Rent |
|
| 4)Other Items |
|
| What is the full replacement cost of the: |
| a)House contents you are insuring?(which means
furniture,household goods,personal effect of the insured or
any member of his family normally residing within,fixture
and fittings)? |
|
| b)Items valued more than =N=75,000.00 |
| ITEM |
AMOUNT |
|
|
|
|
|
|
|
|
|
|
|
|
| c)Jewellery,articles of gold,silver or precious
metals,gem stones,furs and works of art: |
|
| ITEM |
AMOUNT |
| |
|
|
|
|
|
|
|
|
|
|
|
|
|
I hereby declare and agree that:
|
|
To the best of my knowledge and belief, the statements made by me
or on my behalf are true and complete. |