Fire Insurance Proposal Form

Full Name of the Proposer
Address of the Proposer
Name and Address of Partner/Bank, if any
Trade of Profession
Period of Insurance From
To

Risk To Be Covered

Cyclone & Flood
Riot & Strike Damage
Malicius Damage
Earthquake
Electrical Clause
Night Work
Hail Storm
Terrorism
Explosion
Aircraft & Aerial Damage
Subterranean Fire
Impact Damage
Land Slide
Artificial Light

Valuation

As Per Diagram Attached
Description of Property Insured
Serial No
Description
Amount ( Tk )
1.
2.
3.
4.
5.
6.
7.
8.

Situation of Premises

Name of Building
Owner of Building
Plot / Holding No
Street
Town & District
Is the building detached?
If so, state distance of nearest buiding.
Does the Building adjoin another Building? If so, is the dividing wall a perfect party wall which is 13 inches thick, carried through atlenst 18 inches above the roof having no opening therein except for shafts, straps, steam gas and water pipes sufficient size for the purpose and not exceding 4 square feet in area?

Construction of Premises

Number of Stores
Construction

Occupation of Premises

Occupation of Building
Occupation of the adjoining Building
Is any trade of process of manufacture carried on the Building

Lighting, Heating and Power

How is the Building Lighted
State full particulars of any power used in the building
Whether any naked light is used inside the premises?

Storage

Are Hazardous goods stored
in teh Building ?

General Information

How long have you carried
on this business ?
Name of Banker and whether
interested in insurance ?
Are The Stock Books kept in
Fire Prof Safe ?
Do you keep a duplicate
set in other premises ?
Are there any Existing insurance on same property with this or any other office ?
Are there any other circumnstances which appear to increase th risk? if so, give particulars ?
Has any Insurer for reason wbarsoever ?
Have you or your partner ever had a loss by fire ?
What assistance can be relied upon in case of fire?
Describe fully Fire Extinguishing appliance on the premises, if any ?
Mention the distance of the nearest Fire Brigade Office.