Electronic Equipment Insurance Proposal Form
 
1
Please select the country/city where the form is to be submitted
Name of the Proposer
Address of Proposer.
Telephone No:
Fax No:
E-mail Address.
Type of business.
Location of equipment to be insured (address of building, storey)
2
Has any of the equipment to be insured previously been covered by other companies?
If so which items of the specification and by which companies?
State when the insurance is to commence.
Date: Time: Period of the insurance to expire at the same date and time next year.
3
Is all the equipment to be insured new?
If not, which items of the specification are second-hand?
What equipment can still be obtained ex works?
State items of the specification
4 Condition of equipment
  Is the equipment maintained in accordance with the manufacturers' instructions
5 Quality Of staff
  Have operators been trained with the manufacturer?
6 Is there a risk of flood and inundation?
If so, by
7 Are dangerous materials used in the vicinity?
  If so, specify
8 We hereby declare that the statements made by us in this Questionnaire and Proposal are, to the best of our knowledge and belief, complete and true, and we hereby agree that this Questionnaire and Proposal forms the basis and is pat of any policy issued in connection with the above risk(s). It is agreed that the Insurers are liable in accordance with the terms of the policy only that the Insured will not lodge any other claims of whatever nature. The Insurers undertake to deal with this information strict confidence.
Item No Description of items 1
Please give full and exact description of all equipment, including name of manufacturer, type, serial number, voltage, power input, etc. In the case of outdoor lines, indicate length and method of laying.		 Year of manufacture Remarks
Give particulars of any part of the equipment to be insured which has had a breakdown or failure during the last three equipment, state means and frequency of transport, areas of operation and distances.
Please state of picture or admitter tubes are built in.		 A2

B3		 Replacement value
Please state current cost of replacing the equipment by new equipment of the same kind plus freight of the same kind plus freight charges, customs duties, costs of erection, package material.
 

 

[ To download the form please rightclick the Download button and select "Save target as" and Save.]
 Download the Form                Download Acrobat Reader
Top