PAX INSURANCE COMPANY LTD
PLOT 3,COLVILLE STREET,PLATINUM JUBILEE HOUSE
P.O9.BOX 7030,KAMPALA
TEL 414 233096/89, 312 266 163 FAX 414 233141
PROPOSAL FOR HOUSEOWNERS AND HOUSEHOLDERS POLICIES
Full Name of Proposer …………………………..………….………………………………………………
(Please use Block Capitals and if a lady state whether single, married or widow)
Address of Proposer……………………….……………………..…………………………………………
Profession or Occupation ………………………………………..…………………………………………
Address of dwelling at which the insurance is required, including Plot No. ……………..……………
Period of Insurance:
From: ………………………
To: ………………………………… at 4:00p.m.
QUESTIONS TO BE ANSWERED BY PROPOSER
(All questions MUST be answered)
1. Of what material is the dwelling a)
b)
.Walls? ……………………………………………………
Roof? ……………………………………………………
2. What is the height in storeys? …………………………………………………………………………
3. How are the outbuildings (if any)
a)
Wall?
b)
Roof?
4. Is any business, profession or trade carried on in any portion of the Premises of which the
dwelling forms a part? If so, give particulars ……………………………………………………
…………..…………………………………………..…………………………………………..……
5. Is the Dwelling:a) A private dwelling house? ……..…………………………………………………………………
b) A self contained flat separate entrance exclusively under your control ……………………..
c) Rooms not self-contained sate whether (a) (b) or (c) ………..………………………………..
6. Is the dwelling solely in your own occupation? ……………………………………..……….……..
(including your family and servants) ………………….…………………………..…………………
7. If not solely in your own occupation, do you let apartments or receive boarders? ………..……
…………………………………………..………………………………………………..………………
8. Will the dwelling be left without an inhabitant for more than 60 days in all during any one
year? ……………………………………………………..………………………………………………
9. Are buildings in a good state of repair and will they be so maintained? ………………………...
…………………………………………..……………………………………………………….………
10. Has any Company or insurer, in respect of any of the Contingencies to which the proposal
applies:-………………………………………………………………..………………………………..
a) Declined to insure you? …………………………………….…………..…………………………
b) Required special terms to insure you? ……………………………………...………..…………
c) Cancelled or refused to renew your insurance? ………………………………………………..
d) Increased your premium or renewal? ……………………………………………………………
If so, give full particulars ………………………………………………..…………………………
11. Have you ever sustained loss from any of the herein mentioned perils? ………………………..
If so, give particulars……………………………………………………………………………………
12. If this proposal is in lieu of any insurance with this company, please give particulars
………………………………………………..…………………………………………………………
…………………………………………………………..……..…………………………………………
13. Have you any other policies in force covering any of the contingencies to be insured against?
If so, please give particulars ………………………………..…………………………………………
14. If the dwelling is a flat, is it on the ground floor? ………………………………………..………….
15. Are all windows of the dwelling protected by expanded metal or iron bars? …………………..
…………………………………………..……………………………………………………………….
PROPERTY TO BE INSURED
A. THE BUILDINGS – HOUSEOWNERS SECTION
Location ……………… Plot No. …………………….. Road ……………. Town …………………
Construction: Walls
Roofs
SUM INSURED:
If buildings only are to be insured, questions 5,6,7,14,15 and 16 need not to be answered.
B. THE CONTENTS – HOUSEHOLDERS SECTION
Detail below the full description and value of various items to be insured:Item
Description
This Policy does not cover:i)
Property more specifically insured
ii)
Deeds, bonds, bills of exchange, promissory notes cheques, travellers cheques,
securities for money stamps, documents of any kind, cash, currency notes,
manuscripts, medals, coins, motor vehicles and accessories and livestock.
iii)
Any part of the structure or ceilings of the building wallpapers and the like or external
television and radio antennae, aerials, serial fittings, masts and towners.
DECLARATION
I do hereby declare that the above answers and statements are true, and that I have withheld no
material information regarding this proposal. I agree that this declaration and the answers above
given as well as any proposal or declaration or statement made in writing by me or anyone acting
on my behalf shall form the basis of the contract between me and the company, and I further
agree to accept indemnity subject to the conditions in and endorsed on the company’s policy. I
also declare that the above total represents not less than the value of the property as above
mentioned.
Date ……………….…………….. Signature of Proposer ……………..…………………………..
The liability of the company does not commence until the proposal has been accepted and
first premium paid.