Application risk description (Please use typescript or capital letters)

Transcription

1 Application risk description (Please use typescript or capital letters) Policyholder Name of company / First and family name Commercial registry code / Personal identification code Address (street, house No., town, rural municipality, county, postal code) Telephone Description of activity Line of business Insurance location address Surrounding areas (%) Dwelling houses Commercial buildings Industrial buildings Unused area (Raw) materials/ goods used and/or sold Short description of the production process (in case of a production company) Work organisation Number of employees.. Working time Number of shifts. Number of employees per shift How many days a week in operation?. Building(s) and structures Purpose of the building / Activity at the location Owner of the building (name, address) Load-bearing constructions of the building Wall structure (non-load-bearing partition walls and load-bearing walls) Interim ceilings (between floors and roof bearing structures) Is the plot under the building mortgaged?: no yes (reinforced) concrete brick stone wood glued laminated timber steel/metal steel/metal covered with a fireproof protective layer or a layer that inhibits the influence of fire (reinforced) concrete brick stone wood metal (metal frame) sandwich-panel other. fireproof insulation (glass wool or rock wool) combustible insulation (polyurethane foam, etc.) (reinforced) concrete stone wood steel/metal sandwich-panel other. fireproof insulation (glass wool or rock wool) combustible insulation (polyurethane foam, etc.) Other information about the building(s) Building roof covering material

2 Year built... Renovation is considered to be the total renewal of the named system or part of the building Electrical system renovation year... Roof renovation year... Type of heating system and renovation year... Piping renovation year... Closed net surface m 2 / gross surface m 2 Cubic volume m 3 Surface area of the room(s) used by the policyholder m 2 Total number of floors On which floor are the company premises located?.... Territory Is the territory surrounded in full with a fence: no yes material and height of the fence... Does the territory have gate surveillance: no yes Lighting of the territory: very good good average bad none Are cars entering the territory registered: no yes Protection methods against burglary Is the insured building / Are the insured rooms equipped with a surveillance system: no yes Name of company that installed and maintains the surveillance system Age of the surveillance system... Installed sensors: magnetic sensors infrared / scope sensors... Alarm communicated: locally to the guard room at the site to a mobile phone. To how many numbers?.. to the security company; name of security company... Which areas are covered by the security alarm: Entrances to the building (more detail, if necessary:......) Entrances and openings of all rooms (more detail, if necessary:...) Perimeters of the whole building and all rooms (more detail, if necessary:...) (More detail, if necessary:...) Is there manned surveillance at the site: no yes Executer of surveillance: own employee security company, name... other... Number and location of people executing surveillance:... Video surveillance: no yes. How many cameras and where? Are the entrances to the building(s) equipped with security doors: no yes Are the entrances to the building(s) equipped with security locks: no yes Are the windows and doors of the building(s) equipped with bars or a security curtain: no yes Fire protection methods Is the insured building/ Are the insured rooms equipped with a fire alarm: no yes Name of company that installed and maintains the alarm system Age of the alarm system... Installed sensors: smoke detectors heat detectors... Alarm communicated: locally to the guard room at the site to a mobile phone. To how many numbers?. to the security company; name of security company Which areas are covered with the fire alarm system:... Has a sprinkler system been installed in the building: no yes. Latest check-up carried out on..... Which areas are covered with the sprinkler system:... Are there fire extinguishers at the site: no yes, latest check-up Are there fast fire extinguishing poles at the site: no yes, latest check-up Nearest fire brigade... Distance of fire brigade (km)... Are there flammable and explosive substances in the building: no yes, more detail:..... Loss events that have taken place within the past 5 years (including uninsured/ non-indemnified cases) Possible threats (Cause of damage, scope and amount of damage) Other fields of activity practiced in the building in addition to Name of field of activity Surface area it takes up in the building

3 the main activity of the policyholder Insurance sums and coverage Insurance sums include value added tax Insurance sums do not include value added tax Insured object Insurance sum (EUR) Required scope of coverage Building Carcassing of building / Carcassing of building including commonly used premises Physical share of building / Investment in repairs of rented or hired premises Facilities / Additional facilities limit Names of facilities together with sums insured Office equipment Furniture Supplies with first risk Production equipment Names, purpose, year of production and sums insured of production equipment Goods

4 Description of goods Other movable property Description of other movable property Movable property located outside place of Names of objects making up movable property located outside place of with sums insured Requested deductibles (EUR) Building / parts of building: Movable property: Would you like to have glass and sign? no yes, for the glass of ground floor exterior windows and doors yes, for other glass (describe) Glass first risk indemnity limit EUR.. Deductible EUR 100, other deductible Would you like to have coverage against floods caused by storms or downpours? no Would you like to have coverage against damages caused by short-term ice and snow weight? no Would you like to have coverage against lost income from rent? no yes, requested indemnity limit. Maximum length of indemnity period is 12 months other period: Would you like to have coverage against expenses following an insured event (rent of replacement premises and equipment etc.) for continuing business activity? no Would you like to have general liability? no yes Requested sum (EUR):.. Requested risk of own account (EUR): Insurance conditions Remarks Insurance conditions: Corporate property conditions 1/2014 (valid from ) Commercial general liability terms and conditions 1/2013 (valid from ) General terms and conditions 1/2008 (valid from ) Indemnity regulations 1/2012 (valid from ) Seesam does not offer immediate coverage (Law of Obligations Act 439) (use an additional page if necessary)

5 Policyholder s signature I have submitted objective data for the compilation of an offer and am aware of the consequences of submitting inaccurate data. I have received and read through the general terms and conditions applied to an contract. I have been introduced to and I am aware of the content of clauses in laws and regulations concerning personal data, and I give my consent for the processing of submitted personal data. I undertake to notify Seesam immediately of any significant changes in important circumstances or personal data in a format that can be reproduced in writing. Date of filling in the application Name of person filling in the Policyholder s signature application Insurer Application received by a representative of Seesam Seesam Insurance AS Vambola 6, 10114, Tallinn, business registry code Telephone , seesam@seesam.ee Name of the representative of Seesam who received the application Date Representative s signature