PROPOSAL FORM FOR FIRE INSURANCE
Name of Proposer
Business/Occupation
Address
Current Address:  
Contact Phone
Email Address
Address
 
(a) i. Building (Superstructure Only)
NRs.
ii. Plinth,Foundation, and Compound wall
NRs.
iii. Furniture, Fixture and Fitting
NRs.
2. Particulars of property to be insured showing separate value for each item and each section :
(a) i. Building (Superstructure Only)
NRs.
ii. Plinth,Foundation, and Compound wall
NRs.
iii. Furniture, Fixture and Fitting
NRs.
(b) Plant, Machinary & Accessory
NRs.
(c) Content/Stock-in-Trade (Describe fully)
NRs.
(d) Stock -in-process
NRs.
(e) Stock-in-Open
NRs.
(f) Stock-in-Detached Godown
NRs.
Total Sum Insured NRs.
3. Situation (Give full address) i.e. Muncipal No., Name of building (if any) Street, Ward, Town, Village
 
4. Construction :  
(a) External Wall built of
(b) External Roof built of
(c) Intervening Floor built of
(d) No. of Storeys including basement/attic/loft
5. Occupation of entire building  
(a) By proposer
(b) By other, if any
(c) If used for shop and godown, state nature of good stored
(d) Details of process or manufacturing. If any, carried on
6. Is building detached ? If not, give construction and occupation particulars of adjoining building : Nature of communication by perfect wall or otherwise
7. do you keep regular books of account ?
8. (a) State any other information material to this Risk
(b Describe nature of fire extinguishing appliance in premises, If any.
9. (a) Is Proposer at present or had he Insured property now proposed for Insurance ?
(b) Has Proposer ever sustained loss by fire or other perils ?
(c) Has proposer made any claim under fire Insurance Policy ?
(d) Has any Company  
  i. Decline proposal or cancelled Insurance
  ii. Required special terms or refused renewal there of ? If so, give details.
10. Do you wish to cover additional perils i.e. Explosion, Riot/Strike, Malicious Damage, storm, flood, Earthquake, Aircraft Damage. If so, please specify.  
 
Period of Insurance From: To:
       
Place:      
Date of proposal:      
 
I/We Declare that foregoing statement are true to best of my/our knowledge and belief:
 
 
 
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