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Home » Burglary Proposal Form

Classes:	(private or Company)
From:
To:
Time:
Premises:
How Long is unoccupied:
What Extent Is itUnoccupied:
How long Have you been an occupant:
AreYou the sole Occupier of the premises:
Particulars Of other occupant:
Watchman/securityEmployed:
Any Attempt To break Into the Premises:
Steps Taken to prevent further entry:
Wall:
Roof:
Details of Anti-theft devices Installed:
Name Of maker:
Model:
Date of manufacture:
Size:
Weight:
Cost:
Wheather Free Fixed or free:
Wheather new Or Second Hand:
Burglar Alarm installed:
Specification Of burglar Alarm:
Arethe Valuables Secured:
Do You take Stock Regularly:
Purchase And sales books:
Exact Amount of loss:
WillYou keep books:
Do you keep receipt of purchase:
Current Insurance Against burglaryrisk:
Has renewa lbeen refuse or notivited:
Have you proposed burglary insurance:
Is the proposal Declined or Cancelled:
Has increased rate been required:
Details of increase rate:
Date of proposal:
Insurance policy No:
Description:
Amount of proposed insurance:
Amount:
Current insurance company:
Sustained loss related to insurance:
Claim on insurance for a loss:
Date of loss:
Amount of loss:
Precautions Taken:
Additional facts:
Details of Additional facts:
Declaration Date:
Policy No:
Agency:

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