indicates mandatory fields

1. DETAILS ON PROPOSER

Title

First Name

Surname

Address of property to be insured


Occupation

Are you the sole owner of the premises? Yes No
If no, state Name & Address of other party
Is there any loan / mortgage interest on the property? Yes No
Name & Address of mortgagee or other interest

2. JOINT PROPOSER'S DETAILS (If Relevant)

Title

First Name

Surname

Relationship to proposer

Occupation

3. SECURITY DETAILS

Is the dwelling occupied during the daytime? Yes No
Do you have a smoke detector? Yes No
Do you have an electronic security system? Yes No
  If yes, please state firm:
4. TYPE OF COVER

What type of cover do you require?

Contents Cover

State amount to be insured

State the value of electronic equipment included

Highest single item value

Buildings Cover

State amount to be insured


(To include building(s), pools, jacuzzis, gates, fences & paved areas where applicable)

All risks cover for specified items (Optional - available only if contents insured)

Geographical Limit

A detailed list required at inception. Please type the value of the item(s) in the slots provided

Jewellery
 		Cellular Phones
Photo/video Equipment
Electronic Equipment
Sports Euipment
 		Computers
Art Work
External Satellite Equip
Glasses / Contact Lens
 		Other Collectables
5. INSURANCE RECORD

Have you previously held home insurance?

Yes No
Insurance Company (if known)

Renewal / Lapse Date

a. Have you or any of your family members living permanently with you:

(i) ever had any home insurance cancelled or refused
Yes No
 
(ii) ever had special terms imposed for home insurance
 Yes No
 
(iii) had any loss or destruction or damage in the last 5 yrs
Yes No
 
(iv) made a claim in the last 5 yrs
Yes No
 
(v) ever convicted of arson / offence involving dishonesty
Yes No

b. Has your home ever been: (i) damaged by flood
Yes No
 
(ii) damaged by subsidence, heave or landslip
Yes No
c. To the best of your knowledge, is there any history in the area of your home: (i) of flooding
Yes No
 
(ii) of subsidence, heave or landslip
Yes No
 
If yes to any of the above give full details:

6. BASIC RISK DETAILS

Type of dwelling

Roof construction


Other:

Wall construction


Other:
Is the building: (i) self contained, having its own separate front door
Yes No

(ii) occupied solely by you & your family as a pvt. residence
Yes No

(iii) occupied as a pvt. resid. only, not as a business prem.
Yes No

(iv) in a good state of repair and will be so maintained
Yes No

Do the amounts to be insured represent the full value
Yes No

If no to any of the above, please give full details:

7. CONTACT INFORMATION

Please select how you would like to receive your quotation and enter the relevant contact details

By Email

By Telephone

By Post (Address)

DECLARATION

The information given above for the purposes of this quotation will be incorporated into your contract if accepted and you will be required to sign a declaration attesting to the validity of all statements given.

General Accident Insurance Company Jamaica Ltd.
58 Half Way Tree Road,
Kingston 10, Jamaica.
Telephone: (876) 929-8451; 929-8454; 929-9643-8
Fax No: (876) 929-1074; 960-1270
Email: genac@cwjamaica.com