Jewellers Block Insurance Policy Proposal Form

Name of Proposer*

Name of Subsidiary/Affiliated Companies*

Address of the premises to which the Policy is to apply*

How long has your business been operational*

2. NATURE OF BUSINESS*

Number of Employees*

Minimum no. of employees including principals in the sales section of your premises at any time during business
hours, including lunch time*

4. VALUATION BASISOn what basis do you require claims to be settled?

(i) Your own stock and bank notes? (The stock figures is to be declared on the basis as in question 4
above)

(ii) Goods in Trust (other than for safe custody) goods on approval, repairs and the like?

Jewellery, Gold, Platinum Goods, Bullion Precious Stones & Pearls

Clocks, Silverware, Plateware and Similar

Watches

(b) What was the Maximum Value of your own stock and goods in Trust (other than for safe custody) and bank
notes at any time during the last twelve months?

6. VALUES OUT OF SAFE Maximum value of ALL items of insurance (including those in window
displays) that are "OUT" of Locked Safe or Strongroom

7. WINDOWS DISPLAY(A) How many of these are there?

Windows

Outside Showcases

(B) Give MAXIMUM values which will not be exceeded of:
(a) Any one

Windows

Outside Showcases

(b) Any one article

(c) Any one pad or tray of articles

(d) In all windows and outside showcases

8. EXHIBITIONS & DISPLAYS(a)(i) Did you during the past 12 months exhibit any portion of
your stock at any exhibition other than one promoted or financially assisted by any public authority or by any
Trade Association or entrusts goods for any display or performance?YesNo

(ii) If so, give full particulars including values

(b) (i) Do you exhibit goods, in any showcase in any hotel, club or elsewhere away from your
premises?YesNo

(ii) If so, give full particulars including values and details of protections (i.e. type of glass, locks
and the likes)

(c) Outside Limit (which also includes Sendings) What limit is required for any one loss for property
elsewhere than at the Proposer's premises stated in question 1 (b)(This limit will not apply to property
in any safe)

9. Are the premises occupied at night by any of the following:*ProposerEmployeeCaretakerNone

10. Are there any openings leading to cellar or basement from outside the shop?YesNo
If so, please give details and protection measures

(a) Outer door

(b) Inner doors

(c) Windows other than Display Windows

(d) Skylights, Fanlights, Roof Openings

(a) Give full details of the type of glass in all your display windows

(b) (i) Are all sections of the windows containing jewellery, gold, silver, platinum, pearls and precious
stones and watches substantially partitioned off from the remainder of the display?*YesNo

(ii) What precautions do you take to protect the rear of your display windows?

(iii) Are they kept permanently locked and keys removed?*YesNo

(iv) Are interior showcases similarly locked and keys removed?*YesNo

(c) AT NIGHT and at all other times when premises are not open for business(i) Are all display
windows and/or outside showcases protected externally by shutters or a grill?*
YesNo

(ii) Give full particulars of such protections and state how they are secured

(iii) Does this protection cover the entire front of your premises?YesNo

(iv) If not give details

(d) During Business Hours:Are all your display windows and/or outside show cases containing
jewellery, gold, silver, platinum, pearls, precious stones and watches protected internally either by:
(i) Fixed grilles covering the whole of the display?YesNo

If YES, give specification of these grilles

(ii) Hanging Glass suspended between the window glass and the display

(iii) Can the internal grills or the suspended glass be reached from under?*YesNo

(a) Is there a Burglar Alarm?*YesNo

(b) If so, give full details with name and a copy of maker's specification to underwriters

(c) Are hold-up/panic buttons incorporated in the system?*YesNo

(d) Is the system maintained under contract?*YesNo

Are the premises monitored by IC TVs?*YesNo

Are the premises monitored by Motion Detectors?*YesNo

Are the premises monitored by Seismic Detectors?*YesNo

Are the premises monitored by Recording System?*YesNo

If YES, please provide details

Was the safe new or second hand when purchased?NewSecond Hand

(a) Provide maker's name of safe

Cost when purchased

Descriptive markings on the door

Approximate size and height

Approximate Age

Any other details

Is the Safe illuminated and visible from the street at night?YesNo

Are ALL the keys (including Alarms, Safe & Strong Room) removed from the premises outside business
hours?YesNo

Are there any other special means of protection?YesNo

If YES, please give details

When was your last annual stock taking?

Do you keep proper records of all sales purchases and transactions?YesNo

Have you ever sustained a loss of or losses?YesNo

If YES, give statement covering the past five years with particulars including the amount of each loss and
if insured whether paid in full or otherwise

Is it your practice to give receipts for goods left with you by non-trade customers for repair, valuation,
sale or any other purpose and to require surrender of such receipts before goods are returned to the
customer?YesNo

Do you use entrustment / approbiation notes in respect of all entrustments?YesNo

What is the Fire Insurance rate on the contents of your premises?

By whom was this quoted?

For what amount is Policy required?

A) On Premises

B) Carrying outside premises Within CityPlease ATTACH a file specifying names of all items
and individual limits in the following format:
Item No. | Name of Item | Limit
Name of file should be " Carrying outside premises Within City "

Carrying outside premises Within UAE (Not Applicable)Please ATTACH a file specifying names
of all items and individual limits in the following format:
Item No. | Name of Item | Limit
Name of file should be " Carrying outside premises Within UAE "

Carrying outside premises Outside UAE (Not Applicable)Please ATTACH a file specifying
names of all items and individual limits in the following format:
Item No. | Name of Item | Limit
Name of file should be " Carrying outside premises Outside UAE "

By Air Freight under AW Bill

By Registered Post

By Registered Air Mail

By Other Conveyances

D) Home Risk

At Customers Premises

At Dealers / Repairers / Cutters Premises

F) Infidelity of EmployeesPlease ATTACH a file specifying names of all items and
individual limits in the following format:
Sr. No. | Name | Nationality | Maximum Limit (AED) Please add Total Aggregate Limit at bottom.
Name of file should be " Infidelity of Employees "

Reference 1

Reference 2

Have Llyods or any other insurer ever cancelled or refused to issue or to continue any insurance for
you?YesNo

Have you previously been insured? If so, state with whom, risks covered

Are there any other circumstances or information within your knowledge or opinion that you would like to
state?

I/We have read the above and agree that to the best of my/our knowledge and belief it represents a full and
complete statement.
I/We agree that if this insurance is completed the protections and or safeguards mentioned above shall not be
withdrawan or varied to the detriment of the interests of the underwriters without their consent.
We agree to the terms and conditions of the above declaration.