Order Number “All Risks” Insurance Proposal Form Name of Proposer * Address * Contact Number * Email Profession / Occupation of Proposer * Business Is the residence self-contained and solely under your own control? * Yes No To what extent will the residence be left unattended: By day? By night? Select geographical area in which you wish the articles to be insured; * Insured's Private Dwelling only Insured's Business Premises only Anywhere in Grenada, Carriacou and Petite Martinique Anywhere in Antigua and Barbuda Worldwide Have you at any time proposed for insurance in respect of Fire, Burglary or “All Risks? Yes No Has the risk ever been declined, the policy cancelled, premium increased, renewal refused or special terms imposed? Yes No Have you ever sustained a loss by Fire, Theft or any other risk now to be insured? * Yes No Do any of the risks for which you now propose include jewelry? Yes No Do you possess evidence of value of all the articles to be insured? Yes No Articles to be Insured List all of the articles to be insured and their respective values (in EC$) in the space provided and/or select the button below to upload a list. Declaration: I do hereby declare that the above answers are true, that I have withheld no information whatever that might tend in any way to increase the Company’s risk, or to influence the decision of the Directors regarding the proposal: and I undertake to exercise all ordinary and reasonable precautions for the safety of the said property. I agree that this declaration, and the answers above given shall be the basis of the contract between me and the Company: and further, if the proposal is accepted, I agree to accept a policy, subject to the usual conditions prescribed by the Company and set forth in the Policy. (Privacy Policy) * Insured Name * Date *
