FIRE INSURANCE PROPOSAL FORM

First Name

Last Name

Phone no.

Email

Preferred Method of Contact

Phone

Email

other

Full address(s) of premises proposed for insurance

Address Line 1

Address Line 2

City

State

Zip Code

Country

Construction of Walls

Construction of Roofs

Construction of Floors

Number of storeys (note that a bungalow is regarded as one story building

Age and Condition of building(s)

Method of Lighting (and Heating, if any)

Is any retail trade carried on?

Give details

What manufacturing processes or repair work (if any) are carried on within the premises

What power is used? Electricity, gas or any other source

What other trade or business is carried on by the other occupants (if any) of the premises

Are there any hazardous goods located outside the building(s) and within 10 meters thereof. Please give details

Year of Incorporation

Is the whole building(s) used for business purpose or private dwelling (please give details)

Area of Specialization

No. of Permanent Staff

Name and Address of other Professionals in Use

Name of MD/CEO

Qualifications

Date of Birth

Specialty(s)

Years in Continous Practice

Full Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

To which professional bodies in Nigeria do you belong? State membership status - Member, Fellow, Associate

Desired Coverage Start Date

Current Insurance Provider (if applicable)

Current Coverage Amount (if applicable)

Do you practice outside Nigeria?

Have you or any staff of the firms or other professional in use ever faced a disciplinary committee for: professional misconduct?

Give Details

Has a client, third party or employee ever filed a suit against you for any reason?

Give Details

Number of Qualified Builders/ Engineers in your firm

Details if Specialist Areas

Category of Contractor

DOES YOUR COMPANY CARRY OUT PREEMPLOYMENT CHECK OR OTHER INVESTIGATION

HOW MANY OF YOUR EMPLOYEES ARE CONTRACT STAFF

HOW MANY OF YOUR STAF ARE YOUR BLOOD RELATIONS

WHAT PERCENTAGE OF YOUR WORK NORMALLY INVOLVES PILING OR UNDERGROUND WORKS RAFT FOUNDATIONS OF BUILDINGS OR MORE THAN TWO (2) FLOORS?

Give Details

Does the business operate in multiple locations

Specify how many locations and provide details for each location

By submitting the form you declare that the above statement are true and correct and agree that this
proposal form shall the basis of the contract between us and the underwriter.