BOILERS EXPLOSIONS INSURANCE POLICY PROPOSAL FORM





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






Please also attach copies of their last 2 inspection reports.
Only PDF, Excel, Word & JPG Files are accepted.

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



Which of the following variations do you wish to insure:
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



DECLARATION:
I / We agree that:
a) The information supplied in this proposal is true and complete and that I /We have not concealed, misrepresented or misstated any material fact.
b) This Proposal shall form the basis of my / our contract with MANSARD INSURANCE PLC.
c) Immediate notice shall be given to MANSARD INSURANCE PLC of any alteration in the circumstances described herein.
d) No insurance will be in force until this Proposal has been accepted by MANSARD INSURANCE PLC and premium paid.