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PRIVATE COLLECTOR'S - PROPOSAL FORM

FINE ART & JEWELLERY DIVISION

Answer all questions to the best of your knowledge and belief.

All material facts must be disclosed as failure to do so may nullify and policy or certificate issued.

If you consider that any question requires expert knowledge which you are unable to provide, indicate this in your answer.

1. Name of proposer (s)
    Date of Birth:

    Exact nature of business or occupation of proposer (s):

    Residential address (es):

2. At which address (es) are the items to be insured located:

    Are the buildings constructed of brick, stone or concrete with slated or tilted roof ?:

    If not, state construction and fire rate:

    Are the premises an apartment?

    If so, is it self contained?

    On which floor of the building is it situated?

    Is it a purpose built block?

3. Please specify (answer for each premises)

    Types of locks on external doors:

    Types of window locks or catches

    Burglar alarm:

    Make:

    Method of signaling:

    Does the alarm cover all areas containing the insured items?

    If not, state the extent of coverage

    Are fire/ smoke sensors installed?

    Safe: -  Type:
                 Model:
                 Any other protections:

    4. Will the premises at which the items to be insured are located, be regularly left unattended by day or night?

    If so, give details:

    5. Has the proposer or any member of proposer's household ever suffered loss or losses?

    If so, state

    - approximate date of loss:
    - circumstances and amount of each loss:
    - if insured, whether paid in full or otherwise:

    6. With whom is insurance currently in force?

    7. Has any insurer refused or cancelled insurance for the proposer or any member of the proposer's household?

    If so, give details:

8. Give split values:

Pictures, paintings, sketches, prints and the like, books, statues and     sculptures of a non- fragile nature, items of non-precious metals         or wood

$
Porcelain, pottery, ceramics, glass, jade and other items of a brittle or fragile nature $
Antique furniture $
Clocks, watches, barometers, mobiles and other mechanical art $
Gold, silver and other precious metals $
Other items (give details)   "SEE ATTACHED SCHEDULE" $

9 Are there any other factors affecting this insurance of which you are aware?

I hereby declare that the above statements and particulars, whether in my own hand or not, are true, and that no facts have been suppressed or misstated

I understand that non-disclosure or misrepresentation of a material fact will enable underwriters to void the insurance.

I understand that the signing of this proposal does not bind me (or Underwriters) to complete the insurance but agree that should a contract be concluded, this proposal and the statements made herein shall form the basis of the contract.

____________________________                __________________

Signature of Proposer                       Date


Supplemental Information:

1a. Name of significant other (s):
Date of Birth:
Exact nature of business or occupation of significant other (s):
Residential address (es):
2a. At which address (es) are the items to be insured located:
Are the buildings constructed of brick, stone or concrete with slated or tilted roof ?:
If not, state construction and fire rate:
Are the premises an apartment?
If so, is it self contained?
On which floor of the building is it situated?
Is it a purpose built block?
3a. Please specify (answer for each premises)
Types of locks on external doors:
Types of window locks or catches:
Burglar alarm: Make:
                          Method of signaling:
Does the alarm cover all areas containing the insured items?
If not, state the extent of coverage:
Are fire/ smoke sensors installed?
Safe:- Type:
          Model:
          Any other protections: