PLEASE ANSWER ALL QUESTIONS FULLY; WHERE QUESTIONS DO NOT APPLY, PLEASE INSERT N/A. PROPOSER INFORMATION (Photo Identification and Proof of Address required) 1. First Name: 2. Middle Name: 3. Surname: 4. Date of Birth: 5. Place of Birth: 6. Nationality: 7. Gender: TRN: 8. Home Address: 9. Mailing Address: 10. Work/Business Address: 11. Email Address: 12. Home Phone #: 13. Mobile #: 14. Work Phone#: 15. Type of Identification: 16. Identification Number: 17. Expiry Date of Identification: 18. Occupation/Type of Business: (Describe in full and be specific; avoid vague terms like Businessman, Director ) 19. Name and Place of Employment: 20. Do you have any other type of insurance with JNGI? Yes No If Yes, give details: 21. Are you a Director of any company insured with JNGI? Yes No If Yes, give details: 22. Have you or any relative or close associate been entrusted with Yes No If Yes, give details: prominent public function (e.g. Politician, Senior Government, Judicial or Security Force Officials) in any country? 23. To the best of your knowledge, are you or any close relative (spouse, Yes No If Yes, give details: children, parents or siblings) connected in any way (personal or business) to JNGI or any other member company within the Jamaica National Group)? 24. Period of Insurance: From: To: 25. Source of Funds (used for paying the Insurance Premium): ADDITIONAL PROPOSER INFORMATION (IF PROPOSER IS AN ENTITY) 26. Name of Chief Executive Officer: 27. Name of Contact Person/Authorized Signatory for the Entity: 28. Contact s Relationship to Insured: 29. Contact s Email Address: 30. TRN: 31. Type of ID: 32. ID Number: 33. ID Expiry Date: 34. Names and Addresses of Shareholder(s) with 10% or more shareholding: Name Address 1) 2) 3) 35. Names and Addresses of Directors: Name Address 1) 2) 3) NB: Copy of Certificate of Incorporation for the Entity is required Form #: JNGI-HSC-PROP-v1-Oct. 2015 1 of 6
THE BUILDING AND OR CONTENTS TO BE INSURED 36. Address of Apt #: Street #: Street Name: Town/ District: Post Office/Agency: Parish: the Home 37. In what year was the Building constructed? 38. # of Storeys: 39. Geo Code: 40. Building Sq.Ft.: 41. Is there a Mortgage on the Building? Yes No If Yes, give Name and Address of Mortgagee. 42. Will the Building be left unoccupied for any consecutive Yes No If Yes, give details: period of more than 60 days? 43. Is/Are the building/s in good condition and will it/they Yes No If No, give details: be so maintained? 44. Are any Business goods stored in the Building? Yes No If Yes, give details: 45. Is the Building used for any business or profession of Yes No If Yes, give details: any kind? 46. Has any loss or damage been sustained in the last 3 years Yes No If Yes, give details: on this property? 47. Is this a Waterfront Property? Yes No If Yes, state distance from the waterline: 48. Does the Building have any of the following security features? Yes No If Yes to any of these questions, give details where appropriate. a) Burglar Alarm b) Burglar Bars c) Watchman d) Panic Buttons e) Dogs f) Security Guards (Name the Company) g) Gated Community h) Neighbourhood Watch i) Fire Extinguishers j) Smoke/Heat Detectors k) Hurricane Shutters l) Other (Please specify) 49. Is the Building? Yes No a) A Private Dwelling House b) A Townhouse c) A Self-contained Flat with separate entrance under your exclusive control or that of your immediate family d) An Apartment or Rooms to which occupants other than your immediate family have access 50. Is the Building? Yes No If Yes to c) to f), give details. a) Owner Occupied b) Occupied by Tenants c) Rented by you from someone else d) Rented out on a short term basis e.g. for 6 mths e) All or a part of a Strata Plan f) All or part of a building which exceeds 5 storeys 51. Is the Building exposed to any of the following hazard? a) Flooding b) Landslip c) Hurricane d) Earthquake e) Other Yes No If Yes, give details Form #: JNGI-HSC-PROP-v1-Oct. 2015 2 of 6
52. Has any Insurer refused to insure you or imposed any special conditions 53. Has any Insurer refused to insure the Building or imposed any special conditions Yes No If Yes, give details Yes No If Yes, give details CONSTRUCTION 54. What is the Building constructed of? a) Block and Steel b) Precast Concrete c) Spanish Walls (stone and mortar) d) Nog e) Brick f) Cut-stone g) Timber h) Other (Specify) Walls a) Reinforced Concrete (poured or precast) b) Cement, Spanish, Clay Tiles c) Slates d) Zinc Sheets e) Alu-Steel f) Corrugated Asbestos g) Decra-bond, Mastic Tiles h) Timber Shingles i) Timber Sarking covered with Felt and/or Paroid j) Aluminium Sheet or Shingles k) Continuous Aluminium (any profile) l) Fiberglass Shingles m) Thatch n) Other (Specify) Roof SUMS TO BE INSURED 55. BUILDINGS AND STRUCTURES: a) Main Building b) Domestic Outbuilding c) Boundary Walls (excluding Retaining Walls) d) Retaining Walls/Sea Walls e) Gates, Fences, Hedges f) All Landlord Fixtures and Fittings g) Solar Water Heaters h) Solar Panels i) Air Conditioning Units j) Awnings k) Paved Areas l) Gazebos Radio and Television Aerials and Antennae (other than Satellite Dishes) m) Satellite Dishes n) Generators o) Swimming Pool (including Pool Deck, Pump House, related pipes and fixed pool accessories) p) Water Tanks q) Other (Describe) NB: - The Building Sum Insured must be based on the cost of rebuilding or replacing and not the Market Value; JNGI recommends that you obtain a professional valuation to establish your Building Sum Insured - Claims are settled on a Replacement Basis, provided the sums insured are adequate and the insured items are maintained in a good state, in keeping with the Terms and Conditions of the Policy - You are required to sign the attached Average Clause before JNGI can enter into an insurance contract with you. Sum Insured ($) Form #: JNGI-HSC-PROP-v1-Oct. 2015 3 of 6
56. CONTENTS: Sum Insured ($) a) GENERAL CONTENTS - All household goods, electronic equipment and personal belongings, owned by the Proposer or for which the Proposer is responsible while they are in the Building described above. b) SPECIFIED CONTENTS If any item(s) included in the Sum Insured under General Contents at 57. a) above, is/are individually of a value greater than 5% of the total Sum Insured on the said General Contents (items like Jewelry, Paintings, Sculptures, Cameras, Curios, and the like, Audio and Video Equipment, Televisions, Computers and Accessories, External and Internal Components of Satellite Receiving Systems, C.B. Short Wave and Two-way Radio Systems, and so on), please list them below; you may continue on a separate sheet of paper if necessary. NB: For items not specified below, the Limit is 5% of the Sum Insured on General Contents for any one item with a maximum Limit of 1/3 rd of the Total Sum Insured on General Contents for all such items combined. Specified Contents to be Insured Description/Serial # Sum Insured ($) 57. ALL RISKS: List below all individual items which you wish to insure against Accidental Loss or Damage, in addition to the standard perils covered under this policy. Please continue on a separate sheet of paper if necessary. Sums Insured on All Risks items must not be included in the Contents Sum Insured at 55. above. Please note that Valuations or Purchase Receipts will be needed for items valued over $5,000.00. Items to be Insured Description/Serial # Portable Items: (e.g. Jewelry, Eye Glasses & Contact Lenses; Sporting & Photographic Equipment; Portable Computers; Cellular Phones, and so on) Jamaican or Worldwide Cover Sum Insured ($) Fixed Items: (e.g. Paintings & Works of Art; Cups & Trophies; Personal Computers & Peripheries; Satellite TV Equipment (internal & external); Television; VCR & DVD; Compact Disc, and so on ) 58. Does the Total Sum Insured for Goods under Specified Contents and All Risks combined, exceed 1/3 rd of the Sun Insured on General Contents? REFEREES (Applicable to Individual Proposers) Form #: JNGI-HSC-PROP-v1-Oct. 2015 4 of 6
Name: Name: Address: Address: Telephone #: Telephone #: Occupation: Occupation: DECLARATION OF THE PROPOSER I/We warrant that: - The above statements and particulars which I/We have read and checked are true - I/We have not suppressed or misstated any fact - The vehicle(s) referred to above is/are in good condition and repair I/We desire to effect insurance in accordance with the terms, conditions and exceptions of the Company s standard policy. I/We agree that this Proposal shall form the basis of the Contract between me/us and the Company and shall be deemed as incorporated in the policy to be issued. I/We further declare and agree that if the above statements and particulars have been filled in by a person other than the undersigned, such person shall be deemed to be my/our Agent for the purpose of filling in this Proposal Form. I/We agree to my/our personal information being shared with JNGI s parent company and/or any of JNGI s fellow subsidiaries. I/We further agree that JNGI may record and store all information on my/our account in such form and means it deems fit including use of the services of its parents or fellow subsidiaries and affiliates or any electronic data processing service provider. Signature of Proposer: Date: NB: - If you are signing on behalf of a Company, state the capacity in which you are signing and affix the Company stamp. - At the inception of the insurance, your Policy may not be immediately available and so you may request a Specimen of the Policy in addition to any Explanatory Notes. - All outstanding premiums become payable in the event of an accident or any incident that may give rise to a claim being made against this insurance. Form #: JNGI-HSC-PROP-v1-Oct. 2015 5 of 6
Notice to Insured on the Nature and Effect of the Pro Rata Condition of Average (Average Clause) in Accordance with the Insurance (Amendment) Regulations 2004; Regulations 126 (4) and (5) of the Insurance Act 2001. Name of Proposer(s): Dear Proposer(s), Please note that any property that is insured or to be insured under the policy mentioned above is subject to the Pro-rata Condition of Average (Average Clause). This means that, under certain circumstances, if the property covered under this policy is, at the time of any loss or damage from an insured peril, of greater value than the sum for which the property is insured, you will only be entitled to recover under this policy such proportion of the loss as the Sum Insured under this policy bears in relation to the total value of the property. You are said to be under-insured because the sum insured at the time of the loss is less than the actual value of the insured property and so a part of the insured loss will not be covered under this Policy. In this case, you are considered as being your own insurer for the part of your loss, which is not covered under this policy. For example, should you have a property which has a value of $10,000,000 and you decide to insure for $7,000,000 and you suffer a loss from an insured peril, there are three possible scenarios depending on the size of the loss. The formula that is applied in each case is as set out below. Sum Insured x Amount of the Loss = Amount Recoverable Value 1 1 Example 1 Where the loss is less than value and less than Sum Insured: Assume the loss is $5,000,000 7,000,000 x 5,000,000 = 3,500,000 10,000,000 1 1 You will be paid $3,500,000 or 70% of your loss less any deductible stated in the policy. Example 2 Where the loss is less than value but greater than Sum Insured: Assume the loss is $8,000,000 7,000,000 x 8,000,000 = 5,600,000 10,000,000 1 1 You will be paid $5,600,000 or 70% of your loss less any deductible stated in the policy. Example 3 Where the loss is equal to the value: Should you have a total loss, that is, $10,000,000 then you will only receive the amount you insured the property for that is, $7,000,000.00 less any deductible stated in the policy. However, in respect of Home Owners Comprehensive policies on Private Dwellings and / or Contents contained therein, you may be entitled to the full amount of the insured loss if the Sum Insured is equal to or more than 85% of the value. This will depend on the terms of your Policy. Please review the terms of your policy carefully, including checking on the adequacy of the sum for which the property is insured or is to be insured. This will enable you to identify whether you are or will be under insured in a manner, which will cause the Pro-rata Condition of Average to be applied. You may check with your insurer, agent or broker for further clarification on the terms of your policy and the nature and effect of the Pro-rata Condition of Average contained therein. This notice is given to you in fulfillment of the legal requirement to provide you with information on the nature and effect of the Prorata Condition of Average stated in your policy/ to be inserted in the policy of insurance mentioned above. Please note that the extent to which the condition applies is governed by the terms of your policy. Signed by Insurer:... Signature of Proposer:. Date:. Form #: JNGI-HSC-PROP-v1-Oct. 2015 6 of 6