FIRE & SPECIAL PERILS INSURANCE PROPOSAL FORM

Unless all material facts are disclosed, this insurance could be invalidated. Material Facts are those facts an Insurer would regard as likely to influence the acceptance and/or assessment of the Proposal. If you are in any doubt about whether facts are material, you should disclose them. A copy of the completed Proposal Form will be supplied on request but you should keep a record (including copies of letters) of all information supplied to us for the purposes of entering into this contract. A specimen Policy is available on request

DATE INSURANCE IS TO BEGIN
(which cannot be before the proposal is accepted by the Insurers)

EXPIRY DATE

Name of Proposer:

NIB/TIN#:

Occupation of Proposer:

Policy Currency (B$ / US$):

Postal Address:

E-mail:

Telephone Office:

Telephone Mobile:

Telephone Other:

PROPERTY TO BE INSURED:

7. Full Address:

GPS Coordinates:

Latitude:

Longitude:

Construction of Walls and Roof:

Occupation of the Building by:

a) The Proposer:

b) Others:

10.

a) Distance from the sea:

b) Height above sea level:

c) Number of Storeys:

11.

Name and Address of any Mortgagee:

SUMS INSURED:

12.

Buildings including Landlord's Fixtures and Fittings

13.

Stock and Materials in Trade for which the Proposer is responsible

14.

Business Fixtures and Fittings, Machinery and Plant and other items not insured by 12 & 13 above

On:

TOTAL SUM INSURED:

PERILS TO BE INSURED:

17.

Select one from the list below:

Fire & Lightning only

Fire & Lightning plus Special Perils but excluding *Catastrophe Perils

Fire & Lightning plus Special Perils including *Catastrophe Perils with a 2% Catastrophe Deductible

Fire & Lightning plus Special Perils including *Catastrophe Perils with a 3% Catastrophe Deductible

Fire & Lightning plus Special Perils including *Catastrophe Perils with a 5% Catastrophe Deductible

Fire & Lightning plus Special Perils including *Catastrophe Perils with a 10% Catastrophe Deductible

Other

*Catastrophe Perils are Hurricane, Tropical Storm or Cyclone, Tornado or Waterspout, Rain and Hail, Earthquake,Volcanic eruption, and Fire or Flood caused by any of these perils.

DECLARATION, DATA PROTECTION ACT NOTICE & CONDITION OF AVERAGE NOTICE

Please note that in accordance with the Data Protection Act 2003, the information supplied when arranging this insurance policy may be shared for insurance purposes and services with other companies and organisations. For full details please refer to the Data Protection Act Statement available from Insurance Management (Bahamas) Ltd.

Please note that your Policy is subject to a Condition of Average. This means that if the Sum Insured is less than it should be (known as underinsurance) you will not receive reimbursement for the full amount of any loss the Policy responds to. In the event your property is underinsured then the Condition of Average will operate to reduce the net amount you will receive from a valid claim, in direct proportion to the amount of underinsurance. For example, if you have a Sum Insured that is only 50% of what it should be you will only receive 50% of any valid claim. Similarly, if you insure for 75% of the correct amount you will receive only 75% of any valid claim. The following serves to further illustrate the principle:

Calculation Formula:
Example:

Sum Insured
$100,000

divided
by

Replacement Cost
$200,000

multiplied
by

Amount of Loss
$50,000

Policy Payment (before Deductible*)
$25,000

Therefore:

Amount of Loss
$50,000

less

Policy Payment (before Deductible*)
$25,000

Insured's Contribution
$25,000

*Where a Deductible or Excess exists on a Policy, this will be subtracted from the final payment of any claim after the operation of the Condition of Average.

Please note that in the event of a total loss the policy will pay the lower of the amount of the loss or the sum insured. This means that in the event of you being underinsured and having a total loss you will receive only the sum insured, which will not reimburse you for the full amount of the loss you may have suffered.

The basic concept of insurance is that insured persons contribute to a pool based on the risk (the value of their property) they bring to the pool. If the insured does not pay premium based on his full exposure e.g. if he only insures 50% of his risk, as above, then he has contributed less to the pool than he should. Because of this, he cannot take out of the pool the full amount (100%) of his loss, but rather would get the percentage of the loss that he contributed in premium to the pool, which in the above example is 50%. If you have any questions about the way the Condition of Average may affect you please discuss with Insurance Management
(Bahamas) Limited.

This notice is given to you in fulfillment of the requirement set out in Section 214 of the Insurance Act, 2005, to provide you with information on the nature and effect of the Condition of Average stated in your Policy.

I/We declare that, to the best of my/our knowledge and belief, the particulars and answers are true and correct and that I/we have not withheld any information that is likely to influence the decision of the Insurers in regard to this proposal.

I/We have had the Condition of Average explained to me/us and understand that if the sums insured do not represent the full replacement value of the property insured I/we may be penalized in the event of a claim.

I/We agree that an electronically transmitted signature affixed to this document shall have the force and effect of an original signature.

Signing this form does not bind the Proposer to complete the insurance but it is agreed that this form shall be the basis of the contract should a policy be issued. No liability attaches to the Insurers until this proposal has been accepted.

FIRE & SPECIAL PERILS INSURANCE PROPOSAL FORM

GENERAL QUESTIONS:

PROPERTY TO BE INSURED:

SUMS INSURED:

PERILS TO BE INSURED:

DECLARATION, DATA PROTECTION ACT NOTICE & CONDITION OF AVERAGE NOTICE

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