PROPOSAL FORM FOR BURGULARY/HOUSE BREAKING INSURANCE
 
Name of Proposer
Business/Occupation
Address
Current Mailing Address:  
Contact Phone
Email Address
Address
 
2. (a) Full Address of Premises Containing Property to be insured  
(b) Construction of Wall , Roof & Floor  
(c) Occupation  
(d) If not detached give Construction and occupation of adjoining Premises  
 
3. (a) Are you sole occupier of Premises ? If not give details of other occupants  
(b) How long you occupied ?  
(c) Will Premises be left unoccupied? If so give details  
(d) Will Premises be guarded by Watchman ? If so, give number and time.  
 
4. (a) How many opening are there consisting of Door, Window, Others ?  
(b) Give details of Protection for each opening  
(c) State other Burglary Precaution installed  
 
5. (a) Are Valuables Secured in Safe(s) outside business hours ?  
(b) If so give maker's name, size and whether fixed to floor/wall  
(c) How many keys and with whom and where kept ?  
 
6. (a) Do you keep regular Books of Accounts ?
(b) Give other information material to Risk
7. (a) Is Proposer at present or had insured property now proposed against Burglary Risks ?
(b) Has Proposer ever sustained loss by Burglary ?
(c) Has Proposer made any claim under Burglary Insurance Policy
(d) Has any Insurance Company declined Peoposal cancelled Policy/required special terms for renewal ?  
(e) Has there been any reports of Burglary in Area where the premises is situated ? If so give details  
 
8. Give Particulars of Property to be insured giving full description
(a) Stock Consisting of : Rs.
(b) FFF Rs.
(c) Cash lying in Safe Rs.
I/ We Declare that foregoing statement are true to best of my/our knowledge and belief:
Place Date
 
 
 
 
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