Burglary Insurance Proposal Form
 
Burglary is the felonious or criminal taking of property.

Under Common law, certain factors are necessary to constitute. Burglary or housebreaking and there must be either breaking into or out of premises coupled with intent to commit a felony therein.

Legally the term "breaking" has a very wide meaning. It maybe actual breaking when an unauthorized person creates an aperture for the purpose of gaining entry to a building, or constructive breaking when such a person uses fraud, trickery or threats to obtain entry.

Entry is the further acts, which occur after the breaking in order to accomplish the felony. The piercing of a hole in a shutter constitutes breaking and the insertion of an instrument in the hole to withdraw some article constitutes entry.

Breaking out occurs when a thief secretes himself in a building and subsequently breaks out after committing a theft.

There must be (felonious intent on the part of the person committing the theft. That is the thief must have broken into a building with the intention of stealing. If a person enters a building lawfully and, whilst there, incidentally commits a theft, this is larceny and not burglary or housebreaking. Generally speaking, larceny refers to the theft of property unaccompanied by breaking of the Premises by persons such as employees lawfully on the premises.

Unless expressly insured the Policy will not cover loss or damage to deeds, bonds, bills of exchange, promissory notes, cheques, stamp collection, documents of all kinds, manuscripts,medals, coins, precious stones(inset), business books, money, motor vechiles or livestock, or any property in the open or in out buildings, stables, etc., which are not in enclosed communication with the main building.
Please select the country/city where the form is to be submitted
1. (a) Name of the Proposer in full
   (b) Address in full
  (c) Telephone No:
  (d) Fax No:
  (e) E-mail
2. (a) Situation of the premises containing the property to be insured
   (b) Nature of premises
   (c) How long has the Proposer occupied the premises?
   (d) Is the Proposer the sole occupier?
   (e) Will the premises ever be left without an occupant?
   (f) If so, how often and how long?
3. What business will be carried on by the Proposer in the premises to which the insurance is to apply?
4 (a) Will a complete record of stock received and sold be kept?
   (b) If not,how would the exact amount of a loss be ascertained?
5 (i) What precautions will be taken for?  
  (a) securing outer doors?
  (b) protecting ground floor and basement windows?
  (c) protecting skylights and other means of entrance?
   (ii) Will these precautions always be used when the premises are closed for business?
6 For what sums are the stock, business plant, etc.
  
(a) insured against Fire?
   (b) and with what Insurers?
7 (a) Have thieves ever entered or attempted to enter any premises occupied by Proposer?
   (b) If so, five full particulars, stating when, how access was obtained and the extent of loss
8 (a) Has the Proposer been previously insured against Theft, or applied for such insurance?
   (b) If so with what Insurers?
   (c) Has any application for such insurance been declined?
   (d) Has the renewal of any such insurance been refused or an increased rate demanded.
   (e) Has the Proposer ever made a claim of Theft, or Fire in respect of these or any other premises?
  if so, give particulars

Full Description of the property to be Insured
(To include the whole of the stock and business fixtures and appliances) 		Full Value Amount to be Insured.
1 On Stock-in-Trade consisting of
2 On Goods in Trust or on Commission for which the Proposer is responsible consisting of
3 On Business Fixtures, Fittings and Utensils, Office Furniture, Printed Books, unused Stationery and Office utensils, the property of the Proposer or for which he is responsible.
4 On Furniture, Household Goods and Personal Effects, the property of the proposer or such the proposer's family as permanently reside with him, not including property described under items 5 and 6 below.
5

On Jewellery, Personal Ornaments, Watches, Gold and Silver articles, Furs, and Lace in private use the property of the proposer or his Family, as described in item 4 hereof.
N.B. - No one article (Furniture, Refrigerators, Radios, and Pianos excepted) insured under items 4 and 5 above to be deemed of greater value than 5 percent. Of the sum insured by those items, unless specifically insured.
6 On the following articles not mentioned above:-
Total Sums to be Insured
 


Declaration

I hereby declare that the above answers are true, and that I have withheld no information whatever that might tend to influence the decision of the Company regarding the Proposal, and I undertake to exercise all ordinary and reasonable precautions for the said property, I agree that this declaration, and the answers given shall be the basis of the contract between me and the company, and I further agree to accept a Policy subject to the usual conditions of the Company's Policy.

 

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