THE NEW HOME PROTECTOR EXTRA INSURANCE PROPOSAL FORM

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1 Argus Insurance Agencies Limited La Concorde Tel: Triq Abate Rigord Fax: Ta Xbiex XBX THE NEW HOME PROTECTOR EXTRA INSURANCE PROPOSAL FORM PERSONAL INFORMATION Title: Mr. Mrs. Ms. Other If Other please specify Name: Surname: Identity Card No.: Address: Date of Birth: Business/Occupation: Home Phone No: Mobile No: Postal Address: Second proposer (if applicable) Title: Mr. Mrs. Ms. Other If Other please specify Name: Surname: Identity Card No.: Business/Occupation: GENERAL QUESTIONS - Your Property Period of Insurance From : To: Address of Property to be Insured: a Villa a Bungalow a Maisonette a House a Flat a Penthouse part of a Condominium If it is a villa / bungalow / house, what type? Semi-Detached Detached Terraced Is your Home? If it is a flat / penthouse / maisonette / part of condominium, provide floor level. Is the property for which insurance is required: (tick where appropriate) 1. Built of brick, stone or concrete with concrete roof? 2. Self-contained having its separate, lockable front door? 3. Used as a private residence only and not as a business premises? 4. In a good state of repair, and will this be so maintained? 5. Located below street level? Page 1 of 6

2 6. Has any basements or semi-basements? 7. Do you require the cover for business use? 8. Protected by a professionally-installed burglar alarm with a current annual maintenance contract? (If yes, please provide the name of the installing company) If you have answered No to Questions (1) to (5) or Yes to Questions (6) to (8) above, please give full details: Is the property: (tick where appropriate) 1. Occupied solely by you and your family? 2. Rented furnished? 3. Rented un-furnished? 4. Other (Please provide full details) 5. In an area free from flooding in the last 10 years? If No, please provide full details: Please indicate approximately the year when was your home was built. For how many consecutive days will the building be left unoccupied during the year? Is there any interested party (e.g. Mortgagee)? If Yes, please provide Name and Address and Nature of Interest BUILDINGS INSURANCE Do you require Buildings insurance? The amount to be insured should be sufficient to rebuild your home as new. Do not take into consideration the value of the land or site upon which your home is situated. Also include the value of any: fixtures and fittings, interior decorations, aerial and masts, satellite dishes, solar water heaters, photovoltaic systems, water storage tanks; burglar and fire alarm systems, domestic air-conditioning equipment, outbuildings, garages and greenhouses all designed and used for domestic purpose only; swimming pools (excluding related equipment and machinery), tennis courts, terraces, patios, driveways, footpaths, walls (including rubble walls); gates, hedges and fences, parquet flooring, under floor heating, wall paper and murals, domestic fixed fuel tanks including LPG; chair-lifts, passenger lifts and your share of common areas. Page 2 of 6

3 BUILDINGS INSURANCE: Values to be Insured 1. Rebuilding cost including the value of any fixtures and fittings, parquet flooring, wall paper, interior decorations outbuildings, garages and greenhouses 2. aerial and/or masts, satellite dishes 3. solar water heaters and/or photovoltaic systems 4. burglar and fire alarm systems 5. domestic air-conditioning equipment 6. swimming pools (excluding related equipment and machinery) 7. tennis courts, terraces, patios, driveways, footpaths, walls (including rubble walls) 8. gates, hedges and fences 9. domestic fixed fuel tanks including LPG 10. chair lifts, passenger lifts and your share of common areas Total Sum Insured of Building CONTENTS INSURANCE Do you require Contents insurance? Contents include all possessions belonging to your household or for which any member of your household is legally responsible, including: clothing and other personal belongings, electronic and hi-fi equipment, furniture and all other household goods; fitted kitchen furniture and built-in appliances walk-in wardrobes, mirrors, glass tops, ceramic hobs or tops; swimming pool equipment including vacuum pump and other machinery; any items which are to be insured under the Wider Cover for Personal Possessions need not be included under this section. THE AMOUNT INSURED FOR CONTENTS SHOULD REPRESENT THE FULL COST OF REPLACING EVERYTHING AS NEW CONTENTS INSURANCE Values to be Insured Normal Contents 1. furniture including fitted kitchens, walk-in wardrobes, household goods, clothing, etc Valuables 2. TV, non-portable personal computers, audio & video equipment 3. jewellery and gold 4. silverware 5. watches 6. paintings 7. photographic equipment 8. portable electronic equipment 9. Money Total Sum Insured of Contents Page 3 of 6

4 List any valuable item which is individually of greater value than 1,000: Is there a safe installed in the Home? If Yes, please provide the following info: Is the safe?: Wall-Mounted Free-Standing Under-Floor Make/Model: All Risks' cover for Valuables Any of the following items are classified as Valuables: jewellery, watches, portable audio, video & photographic equipment, mobile phones, musical instruments, sports equipment; pedal cycles, laptops and other portable computer equipment, personal organisers and other electronic devices. Note: Valuations or purchases receipts are required for items valued over 250 Item No Description Unspecified Valuables (Single Article Limit 10% of the Sum Insured or 1000 whichever is the lower) Value - TOTAL PERSONAL MONEY & CARDS INSURANCE Do you require Personal Money & Cards insurance? Limit required Page 4 of 6

5 INSURANCE RECORD Have you any other policies in force covering the property to be insured? Have you or any member of your family living permanently with you :- 1. had any special terms imposed for home insurance? 2. ever had any home insurance cancelled or refused? 3. had any loss, destruction or damage in the last five years? 4. made a claim in the last five years? 5. ever been convicted or are currently being convicted of any criminal offence or contravention involving dishonesty? Has your home ever been :- 1. damaged by storm and/or flood? 2. subject to a break in (or attempted break-in by burglars)? To the best of your knowledge is there, in the area of your home, any history of storm and wind damage and/or flooding? Is there any detail or material fact which you feel we should be made aware of with regards to this proposal? If you have answered YES to any question, please give full details in the space provided below: Page 5 of 6

6 Data Protection Notice To the extent that the information supplied by you, whether orally or in writing, constitutes personal data, including sensitive data within the provisions of the Data Protection Act, you consent to the processing of such data for purposes of administering your proposal for insurance, your Policy, underwriting, handling of claims and also for the purposes of detecting, preventing and suppressing fraud and of keeping statistics. We may be required to collect further information from banks, other insurance companies, insurance intermediaries, brokers or insurance associations. In addition, we may pass some or all of the information to other insurance companies, or insurance associations for underwriting and claims handling purposes and also for the purposes of detecting, preventing and suppressing fraud and of keeping statistics. This also helps us to check the information provided. When we deal with your request for insurance, we may search this information. When you tell us about an incident which may or may not give rise to a claim, we will pass information relating to it to the Malta Insurance Association. We and other companies within our group would like, on occasion, to keep you informed of our products and services, by mail, fax, or other electronic means. Please inform us in writing if you do not wish to receive this information or if you wish to receive such information solely from Argus Insurance Agencies Limited. Moreover, were hereby ask you whether you wish to receive direct marketing information from us by to your address provided below. You have the right to request access to, and rectification of, your personal data held by us by directing your request in writing signed by yourself to the Data Protection Officer, Argus Insurance Agencies Limited, La Concorde, Triq Abate Rigord, Ta' Xbiex XBX 1121, Malta. Argus Insurance Agencies Limited as local representatives of Argus Insurance Company (Europe) Limited is authorised to carry on business of insurance in Malta in terms of the Insurance Business Act 1998, regulated by the Malta Financial Services Authority. Company Registration Number: C597 Declaration You are reminded of the need to disclose any facts which the insurer would take into account in the assessment and acceptance of this proposal. If you have any doubts as to whether certain facts are relevant, ask your local Argus Insurance Agencies Limited office. Failure to disclose all relevant facts may invalidate your policy or may result in your policy not operating fully. Please ensure that you keep a record (including copies of letters) of all information that you supply to us in relation to this proposal. Professional Secrecy Act Information on this form or on any subsequent claim form along with other relevant information may be shared with other Insurers as part of an exercise to combat the ever-increasing problem of insurance fraud. Details shared are limited to what is absolutely necessary within the strict bounds of confidentiality and we will always regard your file as being a document protected by the Professional Secrecy Act. Together we can fight fraud I declare that I have read or have had read over to me, the contents of the completed proposal form and I declare that the information given in it is, to the best of my knowledge and belief, correct and complete and that it will form the basis of the contract between me and Argus Insurance Agencies Limited. I agree that if my answers have been written by any other person on my behalf, other than an employee of Argus Insurance Agencies Limited or any of their Brokers/Tied Insurance Intermediaries such person shall for that purpose shall be considered as being my agent and not the agent of Argus Insurance Agencies Limited. Please specify if you want to receive updates on promotions, or any third party offers: YES NO Proposal Date Signature of Proposer Proposal Date Signature of Second Proposer (if applicable) Argus Insurance Agencies Limited is enrolled to act as an Insurance Agent for Argus Insurance Company (Europe) Limited and is regulated by the Malta Financial Services Page 6 of 6

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