PHOENIX INSURANCE COMPANY LIMITED

COMPREHENSIVE HOMEOWNER'S INSURANCE PROPOSAL FORM.

Title Mr./Mrs./Miss./Dr./Prof.

Surname

First Name

Other Names

Telephone Nos.

Gender:

MaleFemale

WhatsApp No.

Email

Postal Address:

Address of property to be insured:

GENERAL INFORMATION

Required as background to the insurance we are asked to provide for you.

1. Please give full details of a) Your occupation(s) and the nature of your business(es) or profession(s). (Please note: brief descriptions such as 'company director' or 'clerk' are not sufficient) b) Your husband/wife's occupation(s) and the nature of their business(es) or profession(s)

c)Your date of birth

Date

2. Have you had household insurance previously, either with us or any other insurance company? If so, please state the company and the expiry date.

YesNo

Details

3.a) Is your home regularly left unoccupied, e.g. when you and/or your husband/wife are at work

YesNo

b)Is your home likely to be left unoccupied for more than 14 consecutive days in any one-year? i.e. when you are absent from your home on holiday.

YesNo

If yes give details

4.In what year was your home built?(Approximate date if exact year unknown)

5. a) Is your home a

House?Flat?Bungalow?Other?

b) If a house or Bungalow is it

Detached?Semi-Detached?

6. Details of construction

a)Buildings

i) Walls

ii) Roof

b) Fence

7. a) Is your home furnished & occupied solely by you and your household (By household we mean all members of your family permanently living with you)

YesNo

b) Do you have Tenants residing with you?

YesNo

8. Is your home in a Neighborhood watch area?

YesNo

9.Is your home, or any part of it, used for business, trade or professional purposes?

YesNo

If YES give details

10. Has your home or the site on which it stands been ever affected by Storm or flood?

YesNo

If YES give details

11 Have you or any member of your household permanently living with you: a)Ever been refused insurance or had any special terms or conditions imposed by any insurance company?

YesNo

b) Had any property or possessions stolen, lost or damaged in the last 3 years, whether insured or not?

YesNo

If YES give details

12 Do you have a second home or live at any other address, as well as the one to be insured?

YesNo

If YES give details

13. The date when you want cover to start.

14. If you have a mortgage and your mortgagees have specifically requested their interest be noted, please give the name and address of the mortgagees.

Their name

Address

GH¢ 1,000.00 GH¢ 5.00

	Sum insured GH¢	Premium GH¢
SECTION 1 - (BUILDING) (The sum insured must represent the full cost of rebuilding and make allowance for the costs of shoring up, debris removal, architects' and surveyors fees)
FENCE WALL
ALTERNATIVE ACCOMMODATION AND RENT
SECTION 2 - (CONTENTS) CONTENTS Please list items in excess of GH¢1,000: ………………………………………………………………………………………………………… ……………………………………………………………………………………………………….. (Please use extra sheet(s) if need be) Serial numbers of Electrical and Electronic Gadgets required
SECTION 3 – (PERSONAL LIABILITY)
SECTION 4 – (EMPLOYERS' LIABILITY) Number of Indoor Servants and their wages/salaries Number of Outdoor Servants and their wages/salaries Drivers and their wages/salaries
SECTION 5 – (PERSONAL ACCIDENT) PERSONAL ACCIDENT to Insured and immediate family a) Death b) Permanent Disablement c) Medical Expenses (per annum) (Please provide breakdown for each family member)

	Sum insured GH¢	Premium GH¢
SECTION 1 - (BUILDING) (The sum insured must represent the full cost of rebuilding and make allowance for the costs of shoring up, debris removal, architects' and surveyors fees)
FENCE WALL
ALTERNATIVE ACCOMMODATION AND RENT
SECTION 2 - (CONTENTS) CONTENTS Please list items in excess of GH¢1,000: ………………………………………………………………………………………………………… ……………………………………………………………………………………………………….. (Please use extra sheet(s) if need be) Serial numbers of Electrical and Electronic Gadgets required

SECTION 3 - (PERSONAL LIABILITY)

	Sum insured GH¢	Premium GH¢
SECTION 4 – (EMPLOYERS' LIABILITY) Number of Indoor Servants and their wages/salaries Number of Outdoor Servants and their wages/salaries Drivers and their wages/salaries
SECTION 5 – (PERSONAL ACCIDENT) PERSONAL ACCIDENT to Insured and immediate family a) Death b) Permanent Disablement c) Medical Expenses (per annum) (Please provide breakdown for each family member)

DECLARATION: I warrant that the above statements and particulars are true and I hereby agreethat this Declaration shall be held to be promissory and of continuing effect and shall form thebasis of and be deemed to be incorporated in the Contract between me and the PHOENIXINSURANCE COMPANY LIMITED and I am willing to accept a policy subject to Terms prescribed bythe Company herein, and to pay the Premium thereon.

Date

Signature of Proposer

Agent

The liability of the Company does not commence until the acceptance of the Proposal has been intimated by the Company.

DETAILS OF COVER