Office - All Risks
  1. Full Name(*)
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  2. Occupation/Business
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  3. Street Address(*)
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  4. PO Box
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  5. Settlement, Island(*)
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  6. Email(*)
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  7. Telephone(*)
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  8. Work Phone
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  9. Fax
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  10.  
  1. Do You Have Any Other Insurance With Us?(*)
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  2. Have you had any insurance refused or subjected to special terms?(*)
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  3. Have you had any losses during the past 3 years?(*)
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  4. If you have answered “YES” to any of these questions, please provide full details below.
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  5.  
  1. Business Address
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  2. Distance From the Sea
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  3. Business or Trade
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  4. How Long In Operation?
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  5. Number of Employees
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  6. Building Construction
  7. Walls
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  8. Roof
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  9. Year Constructed
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  10. Number of Stories
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  11. Are the buildings



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  12. Do you occupy the whole premises
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  13. If not, what other businesses or trades are carried on?
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  14. Security Details (e.g.: Alarm, Burglar Bars, etc.)
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  15.  
  1. Coverage Required From

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  2. Coverage Required To

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  3. Type of Perils (Select One)(*)
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  4. Sums Insured
  5. BUILDINGS
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  6. Tenants’ Improvements and Betterments
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  7. Furniture/Fixtures & Fittings
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  8. Computers & Ancillary Equipment
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  9. Other Electronic Equipment
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  10. Employees’ Personal Property
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  11. Loss of Rent/Extra Expenses
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  12. Total
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  13. ‘I/We declare that the sums insured mentioned above represent full replacement costs of the items covered. We further declare that we have been advised that at the time of loss, should the sums insured not represent replacement costs that any claim will be settled the same ration as sum insured to value.’
  14.  
  1. I declare to the best of my knowledge and belief the information on this form is true in every respect. I also declare that if anything on this form was written by another person, he or she acted as my agent for this purpose. I agree to keep the property in a good state of repair during the currency of this Insurance. I agree that this proposal and declaration will be the basis of the contract between me and the Insurer.
  2. By selecting the submit button you agree to this statement.