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Name of Proposer
*
Contact Person
*
Address
*
Nature of Business
Previous Insurance Takaful Details
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Office Phone
*
Extension
Cell
Class of Construction
Class I
Class II
Nature of Risk
Residential
Commercial
Industrial
Location of Risk
Value of Building (Rs.)
Value of Machinery (Rs.)
Value of Stock (Rs.)
Others
Sum Covered (Rs.)
Proposed Period of Takaful
From
To
Coverages Required
Please make a selection.
Fire
Riot & Strike Damage
Malicious Damage
Earth quake Fire & Shock
Aircraft Damage
Electrical Clause’B’, Please Specify Amount (Rs.)
Atmospheric Disturbance
Explosion Damage
Impact Damage
Burglary
Other
Security Measure
Armed Guard
Round the clock security guard
Other, Please specify
Detail of fire fighting measure
Fire Extinguisher
Hydrant
Sprinklers
Smoke Detectors
Sand or Water Buckets
Previous Loss History
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