Home Insurance Proposal


Personal  Information
 Title  Name *  Surname *  ID Number * Age Occupation *
Postal Address
 E-Mail Address * Tel No. - Home Mobile Tel No. - Office
Address of Property to be insured

 
General  Questions
(a) Is the home for which insurance is required :- Select YES or NO
i. built of brick, stone or concrete with concrete roof ?
yes no
ii. self contained having its separate, lockable front door ?
yes no
iii. protected by a professionally installed burglar alarm with a current annual maintenance contract* ? yes no
If yes please insert the name of the installing company
* Please note that should you wish to accept the discount given for an alarm, this security will become a     requirement of your policy.  
iv. occupied solely by you and your family as a permanent residence ? yes no
v. used as a private residence only and not as a business premises ? yes no
vi. in a good state of repair, and will this be so maintained ? yes no
vii. used for the hosting of persons, other then members of your household for a fee? yes no
If you have answered NO to Questions i to vi or YES to question vii above please give full details

(b) Is the home a (please tick)

i.

ii. Owner Occupied Rented furnished Rented Unfurnished Other

If you have selected "Other" for any of question (b), please give full details
3. When was your home built ?
4. For how many consecutive days will the building to be insured be left unoccupied during the year ?

 
 

Your Buildings

The amount to be insured should be sufficient to rebuild your home as new. Do not take into consideration the value of the land or site upon which your home is situated. Include also the value of any fixtures and fittings, interior decorations, aerial and masts, satellite dishes, solar water heaters, water storage tanks, burglar alarm systems, domestic air-conditioning equipment, outbuildings, garages and greenhouses all designed and used for domestic purpose only, swimming pools and related equipment and machinery, tennis courts, terraces, patios, driveways, fotopaths, walls (including rubble walls), gates, hedges and fences and your share of common areas and passenger lift.

(a) Do you require buildings insurance ? If YES please complete this Section, if NO go to Section 4. yes no
(b) Enter the amount to be insured €  
(c) Do you wish All Risks Cover for this Section ? This cover is only available for buildings which are not more than 25 years old at date of proposal. yes no
(d) Are you the sole owner of the buildings to be insured ? yes no
If you have answered NO, please state name of other interest and nature of interest ?
 

Your Contents

Contents include all possessions belonging to your household or for which any member of your household is legally responsible (but only to the extent of their financial liability to the owner) including fitted kitchen furniture and built-in appliances which form part of the fitted units. This does not include motor vehicles, caravans, trailers, boats, canoes, surfboats, sailboards, overcraft, aircraft, gliders and any accessory which is designed to be used with any of these, living creatures, trees, bushes or plants of any kind (but not houseplants which you usually keep in your buildings) interior decorations, plans, drawings, securities, certificates or documents of any kind except those defined as money, property owned or used totally or partly for business purpose or connected with the employment, fixed swimming pool equipment and machinery, burglar alarm system and domestic air-conditioning equipment, property more specifically insured by this or any other policy.
Any items which are to be insured under the Wider Cover for Personal Possessions need not be included under this section.

THE AMOUNT INSURED FOR CONTENTS SHOULD REPRESENT THE FULL COST OF REPLACING EVERYTHING AS NEW
Select YES or NO

(a) Do you require contents insurance ?

yes no
   
(b) Enter amount to be insured

€  
   
(c) Does the amount to be insured represent the full value of your contents and will it be so maintained throughout the duration of the policy ?
yes no
   
(d)

If the total value of your valuables (i.e. furs, jewellery, articles of gold, silver or other precious metals, watches, personal adornments, works of art, stamp, coin, or medal collections) exceeds one-third of the Amount Insured on Contents and/or exceeds €20,000 in respect of jewellery, please state value. €  
   
(e) Do you wish to extend cover for your contents on a Full Theft Cover basis (subject to underwriting restrictions)?
 yes no
   
(f) Do you wish to extend cover for your contents on an Accidental Damage basis (subject to underwriting restrictions)?
 yes no
   
(g)
Please specify any articles (not being furniture, household appliances, radio and television sets) of greater value than €2,500 or 5% of the amount insured on contents, whichever is the less
 
ITEM VALUE (€)

Wider Cover for Personal Possesions

Any of the following items are classified as PERSONAL POSSESIONS:-
Jewellery, paintings, watches, audio, photographic and video equipment, binoculars, mobile phones, musical instruments, sports equipment, pedal cycles, home computer equipment, personal orgainisers and other electronic devices.
 
(a) Do you wish to insure any Personal Possesions for All Risk Cover ?

yes no

(b) If YES please specify below item and value to be insured. Valuations will be required to substantiate values to be insured.
ITEM VALUE (€) GEOGRAPHICAL AREA
Personal Accident
Cover under this section is OPTIONAL and a quotation will be given on request
(a) Please complete the members of your household who are to be insured under this section.
Full Name Date of Birth   Full-Time Occupation Part Time Occupation
 
 
 
 
 
 
 
 

(a)

Have you or any member of your household suffered any previous injuries, physical defects or infirmities ? yes no
   

(b)

 Have you or any member of your household sought medical advice or received medical treatment within the past twelve months ? yes no
   

(c)

Do you or any member of your household engage in hazardous hobbies or sports ? (e.g. diving, motor racing, hunting etc.) yes no


If you have answered YES to any of the above, please give full details in the space provided below.


Name and Address of usual Doctor:-

Name Address

 
Home Worker Extension
Cover under this Section is OPTIONAL and a quotation will be given on request.
(a) What trade or profession will be carried out at the premises?
(b) Enter the amount to be insured for Business Contents
(equipment, stocks, materials and trade samples which you own or are held in trust, used in your home and in connection with your business).

Insurance Record
(a) Have you any other policies in force covering the property to be insured ? yes no
(b) Have you or any member of your family living permanently with you:-
 yes no

i. ever had any home insurance cancelled or refused? yes no
ii. ever had any special terms imposed for home insurance ? yes no
iii. had any loss, destruction or damage in the last five years ?
yes no
iv. made a claim in the last five years ?
yes no
v. ever been convicted or are currently being convicted of any criminal offence or contravention involving     dishonesty? yes no
(c) Has your home been

i. damaged by storm and/or flood ? yes no


ii. subject to a break in (or attempted break-in by burglars)? yes no
(d) To the best of your knowledge is there, in the area of your home, any history of storm and wind damage and/
      or flooding ?

 yes no
(e) Is there any detail or material fact which you feel we should be made aware of with regards to this proposal ?

 yes no

If you have answered YES to any question, please give full details in the space provided below.

 

DECLARATION - VERY IMPORTANT

You are reminded of the need to disclose any facts which the insurer would take into account in the assessment and acceptance of this proposal.

If you have any doubts as to whether certain facts are relevant, ask your local GasanMamo Insurance office. Failure to disclose all relevant facts may invalidate your policy or may result in your policy not operating fully.

Please ensure that you keep a record (including copies of letters) of all information that you supply to us in relation to this proposal.

Professional Secrecy Act

Information on this form or on any subsequent claim form along with other relevant information may be shared with other Insurers as part of an exercise to combat the ever-increasing problem of insurance fraud.

Details shared are limited to what is absolutely necessary within the strict bounds of confidentiality and we will always regard your file as being a document protected by the Professional Secrecy Act.

TOGETHER WE CAN FIGHT FRAUD

I declare that I have read or have had read over to me, the contents of the completed proposal form and I declare that the information given in it is, to the best of my knowledge and belief, correct and complete and that it will form basis of the contract between me and GasanMamo Insurance. I agree that if my answers have been written by any other person on my behalf, such person shall for that purpose be considered as being my agent and not the agent of GasanMamo Insurance.

Please specify if you want to receive updates on promotions, or any third party offers Yes   No

You may forward this Proposal Form to us by clicking "Submit Form". Please remember that cover will only commence once we have confirmed it to you in writing.

 

 

Data Protection Notice

To the extent that the information supplied by you, whether orally or in writing, constitutes personal data, including sensitive data within the provisions of the Data Protection Act, you consent to the processing of such data for purposes of administering your proposal for insurance, your Policy, underwriting, handling of claims and also for the purposes of detecting, preventing and suppressing fraud and of keeping statistics. We maybe required to collect further information from our sub-agents, other insurance companies, insurance intermediaries or insurance associations.In addition, we may pass some or all of the information to other insurance companies, or insurance associations for underwriting and claims handling purposes and also for the purposes of detecting, preventing and suppressing fraud and of keeping statistics. This also helps us to check the information provided. When we deal with your request for insurance, we may search this information. When you tell us about an incident which may or may not give rise to a claim, we will pass information relating to it to the Malta Insurance Association.We and other companies within our group would like, on occasion, to keep you informed of our products and services, by mail, fax, e-mail or other electronic means. Please inform us in writing if you do not wish to receive this information or if you wish to receive such information solely from GasanMamo Insurance Ltd. Moreover, were hereby ask you whether you wish to receive direct marketing information from us by e-mail to your e-mail address provided below.

You have the right to request access to, and rectification of, your personal data held by us by directing your request in writing signed by yourself to the Data Protection Officer, GasanMamo Insurance Ltd, Msida Road, Gzira GZR 1405.