Boilers Explosions Insurance Policy Proposal Form

Name of Proposer*

Phone*

Fax*

E Mail*

Website*

Full Business Address*

Location of Boiler*

Means of Identification*

ID Number*

Business or Occupation*

Period of Insurance From*

Period of Insurance To*

Does anybody else have a financial interest in the boiler?*YesNo

Are there any faults or defects in the boiler?* YesNo

Has this or any other boiler used by you suffered damage in the last three years?* YesNo

Has any insurer ever declined to insure you or your property, imposed special terms or cancelled or refused to renew any insurance* YesNo

What is the maximum load on the safety valves?

What is the normal working pressure?

What fuel is used in the boilers?

How frequently is the boiler emptied, properly cleaned and examined?*

Who carries out the cleaning and examination?*

Are the boilers controlled full time by an operator solely engaged in attending them?*YesNo

Is the boiler feed water passed through a water treatment process?* YesNo

What is the value of the boiler?*

Express carriage and overtime costs to expedite repairs?* YesNo

Airfreight costs to expedite repairs?* YesNo

Cover for the foundations of your boiler?*YesNo

Cover for the steam and feed piping?* YesNo

Was the Damage caused to your boiler caused by its own explosion* YesNo

Was the Damage caused to your boiler caused by fire gas explosion?*YesNo

Was the Damage caused to your other property caused by explosion of your boiler?*YesNo

Public liability covers for third party claims following explosion of your boiler?* YesNo

Has any Insurer declined or cancelled your business or imposed special terms?*YesNo

Expected Premium

Source of Funds

Bankers