PROPOSAL FOR ELECTRONIC EQUIPMENT INSURANCE

PROPOSAL FOR ELECTRONIC EQUIPMENT INSURANCE
Name and address of proposer
EMail Address
example@example.com
Type of business
Location of equipment to be insured address of building
Structure of building

Steel Skeletonbrickworkconcretewood
Has any of the equipment to be insured previously been covered by other insurance companies?

YesNo
If so which item of the specification and by which companies
State when the insurance is to
Date

MonthDayYear
Date
Time
Period of the insurance to expire at the same date and time next year

MonthDayYear
Date
Are all the equipment to be Insured new?

YesNo
If so which items of the specification are secondhand
What equipment can still to obtained ex works?
State items of the specification
Condition of equipment
Is the equipment maintained in accordance with the Manufacturers' instructions?

YesNo
Quality of staff
Have operators been trained with the manufacturer?

YesNo
Is there a high risk of flood and inundation?

YesNo
if so, by

bodies of watertorrential rainfallsewer backflowother
Are dangerous materials used in the vicinity?

YesNo
If so, by

acidsprepared or sensitized papersLyestest solutionsdevelopersexplosivesisotopesothers
DECLARATION

It is the duty of the proposer to disclose all material facts relevant to the risk. A material fact is one that is likely to influence our judgment and acceptance of your proposal. If your proposal is a renewal, it should include any change in facts previously advised to us. If you are in any doubt about facts considered material, disclose them. Please note that failure to disclose a material fact or ifany information provided proves to be incorrect, we may void your policy and decline to pay any claim. I/We declare that the statements and particulars made by me/us in this proposal are, to the best of my/our belief, complete and true and I/we agree that this proposal, together with any other information supplied by me/us, shall form the basis of the contract of insurance effected thereon.

I further declare and agree that if the statement and particulars above have been completed in the handwriting of any other person other than the undersigned, such person is deemed to be the representative of the proposer for the purpose of completing this proposal.

Signing this proposal form does not bind the proposer or underwriter to complete this insurance.
Date

MonthDayYear
Date
Signature

Clear
Agent

SPECIFICATION OF ITEMS TO BE INSURED - ELECTRONIC

	items No.	Description of items 1 Please give full and exact description of all equipment Including name of manufacturer, type, serial number, voltage, Power input, etc. In the case of outdoor lines, indicate length And method of laying	Year of manufacture	Remarks Give particulars of any part of the equipment to be insured which has had a breakdown or failure during the last three years and shows and signs of repair. In the case of mobile equipment, state means and frequency of transport, areas of operation and distances Please state if picture or admitter tubes are built in	A2 B2	Replacement value Please state current cost of replacing the equipment by new equipment of the same kind plus freight charges, customs duties, costs of erection package material
1

Total
1. For the insurance of electronic data processing (EDP) equipment, an additional questionnaire for EDP equipment has to be completed 2. In the case of bought equipment, mark "A" 3. In the case of hired equipment, mark "B"
Should be Empty:

PROPOSAL FOR ELECTRONIC EQUIPMENT INSURANCE

State when the insurance is to

What equipment can still to obtained ex works?

Condition of equipment

Quality of staff

1. For the insurance of electronic data processing (EDP) equipment, an additional questionnaire for EDP equipment has to be completed 2. In the case of bought equipment, mark "A" 3. In the case of hired equipment, mark "B"