Insurance SLIP Proposal

INSURANCE SLIP PROPOSAL

Proposer / Insured

Date of Birth:

Intermediary / Broker

Risk Description

Provide a clear, complete description of the subject-matter to be insured, including location, use, and any protective measures in place. Material facts that influence acceptance and terms must be disclosed.

Policy Terms Proposed

Policy Type:

Policy Period Commencing:   to  

Proposed Coverages

Please indicate coverages required. Tick all that apply. Additional coverages must be expressly stated and documented.

Property Damage / Fire & Perils
Theft / Burglary
Third Party Liability
Business Interruption / Consequential Loss
Public Liability / Employers' Liability
Contents and Stock
Other (specify below)

Exclusions (Standard and Noted)

The following exclusions are customary and will apply unless specifically extended in writing: war and civil commotion; nuclear hazard; wilful misconduct; losses knowingly concealed at inception; any loss arising from dishonest or fraudulent acts of insured principals not disclosed. Any deviation from standard exclusions must be declared and agreed in writing by underwriters.

I acknowledge the standard exclusions above and declare that no requested extension of cover has been omitted from this Proposal.

Loss & Claims History

Beneficiary Designation

Designate payee(s) for claim proceeds where applicable. Percentages must total 100% where multiple beneficiaries are named.

Attachments & Documentation

Please indicate which supporting documents are included with this Proposal.

Prior policy schedule(s)/loss runs
Photographs / survey reports
Financial statements (if requested)
Safety / risk management reports
Other documents attached

Declaration and Warranty

The proposer warrants that the information contained in this Proposal is true, complete and correct to the best of the proposer’s knowledge and belief, and that no material facts that would influence the acceptance or assessment of risk have been withheld. The proposer acknowledges that any misrepresentation or omission of material fact may entitle the insurer to void cover from inception or exercise other remedies available under law and policy terms.

The proposer authorizes the disclosure and exchange of information necessary for underwriting, risk assessment, claims handling, and fraud prevention with reinsurers, legal advisors, and other insurers where reasonably required. The proposer further agrees that all statements made in this Proposal shall form the basis of any policy issued.

I certify that I have read and understood the Declaration and Warranty above and that the information provided is complete and accurate.

Acknowledgement

The submission of this Proposal does not bind the proposer or any insurer to accept cover. Coverage, terms, and limits are subject to underwriting approval and issuance of a policy or slip by the insurer(s). Any agreed terms must be confirmed in writing. Premiums, endorsements and warranties will be as set out in the policy documentation.

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