COMPULSORY COMMERCIAL INSURANCE PROPOSAL

PLEASE COMPLETE THIS IN BLOCK LETTERS

Full Name of Proposer

Address

Occupation /Business

Tel

Email

Date of Birth

Date

SITUATION of Property to be insured

Built with

Roof with

Year of construction

The BUILDING OF THE PRIVATE DWELLING HOUSE and domestic offices stables garage and outbuildings including landlords fixture and fittings on the same premises and used in connection there with SUM INSURED GH¢

External Walls gate and fences around and pertaining there to SUM INSURED GH¢

HOUSEHOLD GOODS AND PERSONAL EFFECTS of every description the property of the proposer or of permanently resident members of the family and of servants in the above building SUM INSURED GH¢

DESCRIPTION OF ANY OTHER PROPERTY TO BE INSURED

Building of business Premises occupied for

ii On Fence walls pertaining thereto

iii On fixtures and fittings

Raw Materials consisting of

Semi Finished goods / Work-in-progress

Finished goods consisting of

On Plant and Machinery

Any other property to be insured

TOTAL

If yes, please give details

If yes, please state name of company concerned

Is the property proposed for insurance already insured with another Company?

If yes, please give details

Are there any fire extinguisher on the premises?

YesNo

If No, when will they be installed?

If yes, how many and which type?

Are there "No Smoking" signs displayed within the premises?

YesNo

If No, when will they be installed?

Please name any other fire fighting facility installed in the premises.

How frequently is stock inventory taken

Are account books kept up to date

Date

When did you take last physical stock inventory

Are the account books locked up in a fireproof safe or removed to another building at all times when the premises are not open for business purposes

Are any hazardous goods kept in the building?

YesNo

If so, state details and quantity

Has any other person or firm a mortgage or other interest in the property?

YesNo

If yes please state details

Do you wish to be covered for the following additional perils?

YesNo

If yes, please indicate additional perils:

Note:Cover against any of the above perils will be subject to the Company's standard policy Terms, Exceptions and conditions.

Limit of Third Party Liability required for Property Damage/Bodily Injury/ Death

Description of Premises (e.g. warehouse, office, factory, hospital)

Insurance commence on

Date

Ending

Date

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 if any 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.

| 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

Signature

Agent Broker

COMPULSORY COMMERCIAL INSURANCE PROPOSAL

DETAILS OF THE PROPOSED INSURANCE

SECTION A: PRIVATE PREMISES ONLY

(Any article which exceeds in value 5% of the sum insured must be specified and insured separately below)

SECTION B: BUSINESS PREMISES ONLY

NB: Where there are more than one building a separate schedule should be prepared and attached

On stock in trade

Has the proposer ever suffered loss or damage by fire or any other peril?

Has any insurance company or Underwriter ever refused a proposal from you or cancelled or refused to renew your policy?

If the proposed insurance applies to business premises

PERIOD OF INSURANCE