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Things You Need to Know

TOTAL ONE OFFICE INSURANCE POLICY - PROPOSAL

In order to help us decide if we can insure you and under what conditions you must answer all questions on this proposal

GENERAL DETAILS

Date you require insurance from

Full name of proposer(s)

Full postal address

Telephone numbers

Home
Work

Address of Premises where insurance is reqired (if more than one location please specify)

What is the nature of your business? Give full description

How are the buildings constructed?

8.(a)

What is the height of the building (in stories)

8.(b)

On what floor is your business located?

How long have you been in business at your present premises?

Years Months

10.

Are you the sole occupier of the building? If no, give details of the other occupants' business

Yes No

11.

Do you keep cash on the premises after business hours? If yes, how much cash is stored?

Yes No

12.

How are your premises secured at night?

13.

Has any issuer in respect of any risk which this proposal applies:

Declined to insure you?

Yes No

Not invited or reneral or cancelled or refused to renew?

Yes No

Imposed special terms?

Yes No
If you have ticked yes to any of the foregoing, please give details

14.

Have you ever sustained any loss within the last five years for fire, burglary, robbery, flood or burst pipes? If yes, please give details (Date of Loss, Typeof Loss, Brief Description, Amount Paid, Insurer)?

Yes No

15.

Have you ever sustained loss from any peril other than those listed in No. 14? If yes, please give details (Date of Loss, Typeof Loss, Brief Description, Amount Paid, Insurer)?

Yes No

16.

Are you at present insured for any of the risks now?

Yes No

17.

Please enter the mortgagee company if applicable

SECTION 1. - OFFICE COMPREHENSIVE

Interest to be insured		Sum Insured
1.	Loss of/or Damage to the Office Contents & Equipment
(a)	Business books stationary and supplies, ledgers, deeds, plans, documents, manuscripts, records, not including computer tapes and other computer records (excluding the cost of writing or reinstatement)	$
(b)	Furniture Fixtures and Fittings and Internal Decorations, Improvements, Telephone Installation, Gas and Electrical Apparatus and other Machinery not separately insured (excluding glass).	$
(c)	Clothing and Personal Effects of the Insured's Directors, Principals, Partners and Employees excluding property and more specifically insured(Limited to $,1000 per person)	$
(d)	Office Equipment	$
(e)	Works of Art	$
(f)	Other (please specify)	$
	TOTAL	$

NOTE: Coverage under section 1-1 is on a Reinstatement basis (i.e. NEW for OLD). You must ensure that the Sums Insured are adequate to reinstate the propert when new.

SECTION 2. - LOSS OF INCOME

Items to be Insured		Sum Insured
1.	Gross Income	$
2.	Additional Expenditure	$
3.	Accountant charges	$
	TOTAL	$

SECTION 3. - EMPLOYERS LIABILITY/WOKMEN's COMPENSATION

Please select the appropiate box

EMPLOYERS LIABILITY

WORKMENS' COMPENSATION

Please enter employees' details (Occupation of employees, Number of Employees, Estimated annual wages/salaries)

SECTION 3. - DECLARATION AND SIGNATURE

To be completed in all cases

Important notice

Failure to disclose material facts could result in your policy being invalidated. Material facts are those which might influence the accetance or assessment os your proposal. If you are in any doubt as to weather a fact is material you should disclose it.

Please indicate you acceptance to the following by clicking the box:

	I/We hereby declare that the sum(s) to be insured represent the full value of the Interest(s) to be insured.
	I/We hereby declare thath to the best of my/our knowledge all statements given on this Proposal form is/are true and complete and that I/We have disclosed all material facts that ought to be communicated to the insurers.
	I/We hereby declare that if anything on this form is written by another person, he or she acted as my agent for this purpose.
	I/We undertake to exercise all ordinary and responsible precautions for the safety of the insured property.
	I/We hereby agree that this Proposal and this Declaration or Statement made in writing by me/us or anyone acting on my/our behalf shall be the basis of the Contract of the insurance between the Insurers and myself/ourselves.
	I/We agree to accept indemnity subject to the conditions in and endorsed on the Company's Policy.
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