Property Application Form

Insured Information

Insured Name
Main Activity
Address
Contact Person
E-mail
Fax
How long has the comany been in business
Type of CoverageFire & Allied PerilsFire & Allied Perils including Business Interruption

Coverage Period

Neighboring Premises of the insured Location

North
Activity
Distance
South
Activity
Distance
East
Activity
Distance
West
Activity
Distance

Protection System

Do the premises contain any of the following fire fighting facilities

1. Automatic Sprinkles
YesNo
2. Private fire department
YesNo
3. Smoke detectors
YesNo
4. Heat detectors
YesNo
5. Automatic alarm system
YesNo

6. any Special Fire Protection Systems:

- Foam extinguishing system
YesNo
- High expansion foam system
YesNo
- Inert gaseous system
YesNo
- Carbon dioxide system
YesNo
- Dry chemical system
YesNo
- Steam extinguishing system
YesNo
Do you have a maintenance contract for the protection system
YesNo
if yes, please note the name of the contractor
Do you maintain the protection system in house?
YesNo
What is the distance between your premises and nearest public fire brigade?
MetersKilometers

Please complete the following

Building 1
Building 2
Building 3
Building 4
Building 5
Water pumps used for Fire Fighting





Reservoir Water Tanks





Portable fire Extinguishers





Water Supply- Public- Private Tanks- Wells
What is the capacity?

Electrical Power Supply

GovernmentYesNo
Capacity
Private "Generators"YesNo
Capacity

Energy Supply

Type of Energy

Type of Storage
Natural GasYesNo
undergroundon ground
Gas oilYesNo
undergroundon ground
PetrolYesNo
undergroundon ground
OthersYesNo
undergroundon ground
if "Others" list type
Security System / Security ForceManualAutomaticCCTVCommand Center on SiteOutside ContractorInsured EmployeesOthers
Number of Security Guards
If "Outside Contractor", name of contractor
24hr12hrOthers
If "Other" please define

Loss History

Please list five year loss history.

This must include, Type of loss, Cause of Loss, Date of Loss and Total Monetary Value of Loss
What preventative measures have been enacted to prevent re-occurrence?

Risk Information & Values

Building 1
Building 2
Building 3
Building 4
Building 5
Address of Property to be Insured
Occupation / Main Function
Type of Construction
Walls
Roof
Sum Insured
Buildings
Machinery, Equipments & Tools
Computers
Furniture & Decoration
Glass
Business Interruption
Goods in Refrigerator
Stock (Finished or Raw Materials)
Others

Coverage Extensions Required

Machinery Breakdown
Capital Addition
Machinery Breakdown Loss of Profit
Debris Removal

Money:

Cash In Safe
Professional Fees
Cash In Transit
Professional Fees
Tenants & Neighbors Liability
Extra Expenses
Electronic Equipment
Customer's/ Suppliers Contingent Cover
In Land Transit
Theft / Burglary
Rent Receivable
Rent Payable
Fidelity Guarantee

Important Note:

Photos are required with submission of this application form.

DECLARATION: We hereby declare that the statements made by us in this Proposal are, to the best of our knowledge and belief, complete and true, and we hereby agree that this Proposal forms the basis and is part of any policy issued in connection with the above risk(s)

Proposed(s) Name
Date