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Fourth Crescent Road, Asylum Down, Accra, Ghana
+233 (0) 50 818 2597
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Proposal
Form
Title
[Select Title]
Mr
Mrs
Miss
Dr
Full Name
Phone
Email
Property Value
Occupation or Business
Nationality
Additional Information
Situation of property to be Insured
Plot / House No.
Name / No. of Street
Name of Suburb/Locality
Name of Town/City
Roofed with
Sum to be insured
The purpose of building
Residence
Office
Shop
Factory
Warehouse
Other
Description of walls
Where there is more than one building, please indicate separate values for each
Is the Building Detached with an
Outhouse
Semi-Detached
Flat
Storey
If building is under-construction, please indicate
Yes
No
If building is fenced, please indicate
Yes
No
Sum to be insured
If Storey, state the number of Storeys
1
2
3
4
5
6
Contents
INCLUDING HOUSEHOLD GOODS AND PERSONAL EFFECTS of every description, the property of the Proposer or permanently resident members of the family and of servants in the above dwelling.
Note: Any article (furniture, pianos and organs excepted) which exceeds in value 5% of the Amount must be specified below and insured separately.
Sum to be insured (Contents)
On Stock-In-Trade consisting of
On Fixtures, Fittings and Utensils in Trade
On Plant and Machinery therein
Enter sum to be insured
Other Property to be insured
Has the Proposer ever suffered loss or damage by fire or burglary?
Yes
No
If so, give details.
Has any Insurance Company or Underwriter ever refused a Proposal from you or cancelled or refused to renew a Policy?
Yes
No
If so, state name of Company concerned.
Is the property proposed for insurance already insured with another Company?
Yes
No
If so, give details.
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