Household Proposal (Fields marked are Required) Please fill out these few lines including tick boxes where applicable . CONTACT INFORMATION                                           * Contact Name (inc Title)اسم المتصل  والوظيفة   * ASSURED                                اسم المؤمن له   * Address  TEL / FAX / P.O. BOX              العنوان   * Email                                   البريد الإلكتروني Has proposer ever sustained Burglary, Fire or other loss?  Type of Loss & Amount: if any select Yes No   Will the residence be left unoccupied for more than 30 days per year? select Yes No   Please Fill in the sections as per cover required:   Building Contents   Both   Building type:    Private Dwelling House Flat State material facts  of importance to the company: sections of insurance SECTION ONE: Building Details   Sum Insured (If Required) Situation and Description Owner of Building Age of Building Date of last Renovation No: of stories What is the total square of the building? Heating System Select... Electric Electric Heat Pump Natural Gas Oil Propane Solar Other Central Air Select.. Central Air Conditioning Window Units Mixture of Central & Window Units None Smoke Detectors Select... Yes No Security Alarm Select None Yes. Monitored Yes. Not Monitored Fire Alarm Select None Yes. Monitored Yes. Not Monitored Is building Bank Financed Select N/A Yes No Name of Bank SECTION TWO: Contents : (excluding: Jewellery & Furs)         Click here To Fill Out LIST OF CONTENTS Please Type Sum Insured (Please do not use decimal amounts) Fixtures, Fittings & Decoration Furniture Electrical Items Personal Effects (Ex.Jewellery) Other House Hold Items Jewellery  (FILL THE SCHEDULE ATTACHED PLZ)  SECTION THREE : Lost of Rent (due to destruction of building as to be rendered uninhabitable) Max.10% of contents sum insured or JD.5000 whichever is the less       SECTION FOUR : Liability to the Public      (to pay sums which proposer shall be legally liable to pay  to  third parties due to accidents happening in or about the residence).   JD.5000 each loss inclusive of legal costs and expenses SECTION FIVE: Accident Death to Insured/Spouse   Compensation for death of the insured and/or his wife due to Fire or Burglars JD.10000 or 50% of contents some insured whichever is the less. The Principal perils covered by this insurance:  (In  accordance with the usual policy form issued  by the company –    Copy may be optained on  request before effecting the insurance). Fire, Lightning, Explosion of any Property hereby  insured, Bursting or Overflowing of Water Tanks and Pipes, Storm, Tempest, Burglary or Housebreaking, Vehicle Impact (not belonging to the insured or his family), Earthquake, Falling Aircrafts and Flood (As more specifically described in the policy). Additional Covers: Do you wish to extend  Insurance to include :-   1) Extra Lost of Rent Select... Yes No        -A-Rent per Month        -B-No. of Months 2) Sabotage & terrorism Select... Yes No 3) Debris Removal (Limit Of Liability) 4) Architects & Consultants Fees 5) Personal Accident Select... Yes No      -A-Number of persons insured      -B-Details of Insured Person(s)      -C-Accidents to Domestic Servants 6) Accidental Breakage of Mirrors and Glass Select... Yes No I ACCEPT TERMS & CONDITIONS

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