BUSINESS INSURANCE PROPOSAL FORM

Transcription

1 Head Office, Insurance Centre, 30 Samora Machel Avenue, P.O. Box 1256, Harare, Zimbabwe Tel: , , , Fax: , BUSINESS INSURANCE PROPOSAL FORM Name of Proposer : Names of Directors: Postal Address: Physical Address/s: Telephone No.: Address: Nature of Business: Period of Insurance: From to A. FIRE SECTION 1. Buildings $ $ 2. Stock In Trade $ $ 3. Raw Materials $ $ 4. Other Contents $ $ 5. Plant/Machinery $ $ TOTALS $ $ B. LOSS OF PROFITS 1. Gross Profit $ $ 2. Gross Rentals $ $ 3. Fines and Penalties $ $ 4. Claims Costs $ $ Indemnity Period months

2 C. ACCOUNTS RECEIVABLE SECTION 1. Outstanding Debtors $ 0.150% $ 2. Auditors Fees $ 0.150% $ a. For how long have you been in business?.. years b. Do you keep your books of accounts and records securely locked within fire resisting safes or stongrooms at night and at all times when the premises are not open for business, except when such books and records are in use?.. c. Do you adopt any system of duplicating your records? Yes/No If so, state method and where duplicators are kept d. State percentage of bad debt written off in last two years?... D. THEFT/BURGLARY SECTION 1. Qualified Theft* $ $ Note: *Theft following violent entry into or exit from premises. E. MONEY SECTION 1. Not contained in a locked safe/strongroom (petty cash) $ 2. At the residence of directors or $ Employees $ 3. In a locked safe/strongroom or In transit to or from the bank $ $ 4. Seasonal increase $ $ 5. Worldwide business travel $ 6. Crossed cheques $ F. GOODS IN TRANSIT SECTION 1. Goods carried on Insured s own vehicles $ $ G. GLASS SECTION 1. Internal and external

3 glass including lettering and ornamentation $ $ H. BUSINESS ALL RISKS SECTION 1. Office equipment and machines $ 3% $ 2. Cellular telephones $ 15% $ 3. Pedal cycles $ 10% $ 4. Other $ 3% $ I. PUBLIC LIABILITY SECTION Description Limit of Liability Rate Annual Premium 1. General Liability $ 0.15% $ 2. Property Owner s Liability $ 0.15% $ 3. Tenant s Liability $ 0.15% $ 4. Products Liability $ 0.2% x t/over $ 5. Products Recall Liability $ 10% x t/over $ 6. Employer s Residual Liability $ 0.025% x w/bill $ J. GROUP PERSONAL ACCIDENT SECTION 1. Death 3 years current annual earnings 2. Permanent Disablement A percentage of the death benefit 3. Temporary Total Disablement 100% current weekly earnings for 104 weeks 4. Medical Expenses $ K. FIDELITY GUARANTEE SECTION 1. Loss due to theft or fraud by employees or directors $ 10% $ L. ELECTRONIC EQUIPMENT SECTION 1. All computers, printers, faxes, and ancillary equipment $ $ 2. Laptop computers $ $ 3. External Data Media $ $

4 4. Reconstitution of Data $ $ 5. Increased Cost of Working $ $ Indemnity Period months M. MACHINERY BREAKDOWN SECTION a. 1. Generators $ 3% $ 2. Other machinery (coldrooms, etc) $ 1.2% $ 3. Deterioration of Stock $ 0.85% $ 4. Loss of profits $ 0.85% $ N. OPEN MARINE Estimated annual imports $ Estimated annual exports $ Conveyance Air, Rail, Road, Sea Basis of Valuation Gross Invoice Value P. GENERAL INFORMATION SECTION 1. Have you or your partners/directors ever had: a. Insurance refused? Yes/No b. Policies or renewal declined? Yes/No c. Premiums increased or special conditions imposed? Yes/No d. Been insolvent or compromised with creditors? Yes/No If Yes, state when and reasons: 2. Are other insurances now in force? Yes/No If yes state with which insurer and dates of expiry 3. Have you suffered losses for which insurance in now being sought? Yes/No If yes, state details of loss sustained and the date/s of occurrence 4. Are there any parties interested in any of the property insured? If yes, please state

5 Declaration by Proposer/s:- I/We declare that the information contained in this proposal is true to the best of our knowledge, and forms the basis of the contract of insurance between ourselves and the Company. Signed: Proposer Date