All questions marked with * require an answer
Do you have any other insurance with us?*
Have you had any insurance refused or subjected to special terms?*
Have you had any losses during the past 3 years?*
Are buildings equipped with (choose all that apply)
Do you occupy the entire premises?
Type of Perils (select one)*
Sums Insured (estimated amounts)
I/we declare that the sums insured listed above represent full replacement costs of the items covered. I/we further declare that we have been advised that should the sums insured not represent full replacement costs at the time of loss, any claim will be settled using sum insured to value.