Saturday, July 11th 2020

Insured Name (required)

Email (required)

Telephone No.

Mobile No.

Complete Address

Type of Property
ResidentialCommercial

Period Covered

From

To

Years Built

Number of Floors

Total Floor Area (sq. m.)

Insured Value of Building (based on Replacement Cost):

Insured Value of Contents (based on Replacement Cost):

Has the property been renovated or is currently undergoing any type of renovation?
YesNo

Is the property in a flood prone area?:
YesNo

Please indicate the claims history for the last three (3) years:

Questions / Comments / Requests:

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