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AGENCY

Proposal No.

NATIONAL
INSURANCE CORPORATION LTD
(INCORPORATED

IN UGANDA UNDER THE COMPANIES ACT, CAP 110)


HEAD OFFICE: P.O. BOX 7134, KAMPALA
PROPOSAL FOR BURGLARY INSURANCE - BUSINESS PREMISES
(Insurance against BURGLARY and HOUSEBREAKING)

(a)
(b)

(d)
(e )

Name of Proposer (in full) .....................


Address (in full) ...............................
...................................................
Email Address
Tel No
Trade or Business (full description must be given)

Please state:
(a)
Address and Description of Premises containing
Property to be insured (say whether House, Shop, ..........
Warehouse, Factory, &c.) ...
(b)
How long occupied by you? ....... years

Are you the sole occupier of the premises? If not,


give particulars as to other tenants .................

Of what material is the property constructed


(a)
Walls?...........................................
(b)
Roof?.

(a)

(b)

What precautions will be taken for


(i)
Securing outer doors?
(ii)
Protecting grounds floor windows?
(iii)
Protecting skylights and other means of
Entrance

(b)..........
(a) .............
(b) .............
(c) ...............

(a)
(b)
(c)

Do you reside on the premises?


Will the Premises be left unoccupied at any time?
If so, how often, and for how long?

(a)

Has any attempt ever been made to enter these


or any other Premises be left unoccupied by you?
Have you ever sustained loss or damage by
Burglary or Housebreaking? If so, give
particulars and date.
What precautions have been taken to prevent a
recurrence?

(c)
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(iv).
(a) ..........

Will these precautions always be used


when the premises are closed for business?

(b)

(i) ..................
(ii).
(iii)

Have you ever made a claim upon any Company or


Underwriters for loss by Burglary, Housebreaking
or Fire?
If so, give particulars and date ..

(a) .................
(b) ................
(c) .............

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(b)
10

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Have you at any time made a


Burglary Insurance Proposal
If so (a) To whom?
Has a Proposal at any timebeen declined or withdrawn?
Have you ever had a Fire or Burglary Insurance
Policy terminated or renewal thereof uninvited
or refused, or has an increased rate of premium
been required?

....................

Are you at present insured against Burglary or


Housebreaking? If so, give name of Company and renewal
date

...................

(a)
(b)

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(a) .................
(b) ................

State

Do you keep stock and sales


books and will they be posted
promptly?
Will you continue to keep such books?
(a)
(b)

Present Total Value of Contents


Will this be the maximum value of contents
at any one time?

State in respect to Contents


(a)
Amount of Fire Insurance
(b)
Name of Company
(c)
Renewal Date of Policy

(a) ................
(b) ...............
(a) ...............
(b) ..............
(a) ...............
(b) ................
(c) ................

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Have you any other Insurance with


this Company?
If so, give particulars ...................

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SCHEDULE OF PROPERTY TO BE INSURED


State against the following Items (which are all contained in the above-situated premises) the amount to be
insured in respect of each:Rate per cent premium
Sum Insured
(For Office use only)
On stock in Trade
(a)
.....................
..
.
On Goods in Trust or on Commission for which the (b)
.....................
...
..
Proposer is responsible
On Trade Fixtures, and Fittings and Utensils in Trade,
Office Furniture, and Safes (excluding contents)
(c)
.....................
...
..
Cash in locked safe
(d)
.
...
...
On house hold Goods and Personal Effects
Including Furniture, Wearing Apparel
(excluding Furs), Linen, Books,
Cutlery, electro-plate, Clocks, China, Glass Wines
and Cigar, Articles of Vertu, Bric-a-Brac, Musical
Instrments, Cycles, Pictures, Prints and Drawings.
(e)

...
...
On Gold and Silver plate, Jewellery, Personal
(f)

...
Ornaments, Watches, Trinklets and Furs
On the following articles not other wise specified:
..........................................................
(g)

...
.

...
.

...
First Loss Sum to be Insured Ush.

(a)
(b)
(c)
(d)
(e)

(f)
(g)

(h)

Annual Premium
...
(Furniture, Pianos and Organs excepted) shall be deemed of
Odd Time
...
greater value than 5 percent of the total sum insured under
First Premium
...
such items, unless specifically mentioned and separately
insured
Period of Insurance from Until
Unless specifically included the Policy will not cover the Loss of Money, or Secruties for Money. In any form.
No one article included in Items (e) or (f) in this schedule

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I/We hereby propose to effect an insurance with the NATIONAL INSURANCE CORPORATION, and do
warrant the truth and corrections of all the foregoing statements and declare that no material information has been
withheld.
I/We agree that this proposal and declaration shall form the basis of the contract between me/us and the said
Company, and I/We am/are willing to accept the Policy and be bound by all the terms, provisions and conditions
thereof, and to pay the premium thereunder when called upon to do so.
Date ................ Signature of Proposer ...............
AGENT'S REPORT. - I have known the proposer for .... years, believe him/them to be of good
character and repute, I recommend acceptance of this Proposal.
Agent's Signature .................. Address ...............
No liability is accepted by the Company until the issue of the Policy and the payment of the premium, or the
issue of a duly authorised cover note by the Company.
Give full details in full for items proposed.
..........................................................
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