PERSONAL INSURANCE PROPOSAL FORM

Insured:

Postal Address:

Home Address:

Telephone Number:

Risk Address:

Business Address:

Construction of Residence: Walls

Roof:

Period of insurance From:

Period of insurance To:

Renewal date:

House owners comprehensive: Building of the private residence at the risk address in the Section including garages, outbuildings landlords ` fixture and fittings walls, gates, hedges fences courts and swimming pools:

House owners comprehensive sum:

Name of mortgagee:

Mortgage Sum

Householders Comprehensive: Household goods personal effects of every description at Risk address:

Householders Comprehensive:

Please specify Colour Televisions, radios etc and security Arrangements All Risks- Anywhere in the world (Please specify):

All Risk Sum:

Public Liability:

Personal accident:

Insured's Declaration
I apply for the Insurance summarized above, it being understood that where no sum insured is shown against a Section, no insurance is required under that Section. I declare that I have not withheld any material information.

Proposer's Signature:

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PERSONAL INSURANCE PROPOSAL FORM