Electronic Equipments Insurance Proposal Form

Name Of Proposer*

Phone*

Email*

Address of Proposer*

Location of Equipment to be Insured*

Type of Business*

Structure of Building*Steel SkeletonConcreteBrickworkWood

Has any of the equipment been insured previously by other insurance companies?*YesNo

If so, which items of the specification and by which companies?*

DATE*

TIME*

Are all the equipment to be insured new?* YesNo

If not, which items are second- hand?

Equipment still obtained ex-works:

State items of the specification

Is the equipment maintained in accordance with the manufacturers’ instructions?* YesNo

Have operators been trained with the manufacturer?* YesNo

6. Is there a risk of flood and inundation? YesNo
If so, by Bodies of WaterTorrential RainfallSewer BackflowOthers

7. Are dangerous materials used in the vicinity?* YesNo
If so, specify AcidsPrepared or sensitized papersLyesTest SolutionsDevelopersExplosivesIsotopesOthers

SPECIFICATION OF ITEMS TO BE INSURED
Please ATTACH document of all items to be Insured, in the below format:

Item No. | Description of Items | Year of Manufacture | Remarks | A / B | Replacement Value

Description of Items: 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.

Note:For the insurance of electronic data processing (EDP) equipment, an additional questionnaire for EDP equipment has to be completed.

Remarks: Give particulars of any part of the equipment to be insured which has had a breakdown or failure during the last three years and shows any signs of repair. In the case of mobile equipment, state means and frequency of transport, areas of operation and distances. Please state if picture or admiter tubes are built in.
A: In the case of bought equipment, mark “A”.
B: In the case of hired equipment, mark “B”.

DECLARATION
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 part 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 and that the Insured will not lodge any other claims of whatever nature. The Insurers undertake to deal with this information in strict confidence.

We hereby accept the terms & conditions of the above declaration.