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Homeowner’s Proposal Form

Step 1 of 6 - PROPOSER`S DECLARATION

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Proposer's Declaration*
I declare that the information to be provided by me is to the best of my knowledge, true, and that I will not withhold or misrepresent any information concerning the assessment of the risk, and that the vehicle/property referred to is in good condition.
I agree that this proposal and declaration shall form the basis of the contract between me and Gulf Insurance Limited and shall be deemed to be incorporated in the Policy to be issued.
I agree that any breach of this declaration, shall render the insurance cover void from inception.

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PROPOSER DETAILS
Are you an individual or a company?*
Will this be a joint policy?*
- Yes
- No
Policyholder Details
Salutation
First Name*
Last Name*
Date of Birth*
Date Format: DD slash MM slash YYYY
Gender*
Occupation*
Company Name*
Nature of Business
Address 1
Address 2
Town/City*
Country*
Contact No.
Email*
Are you a resident or citizen?*
Of which country are you a citizen?*
Are you a politically exposed person?
Please provide further details*
Other
Policyholder Details
Salutation
First Name*
Last Name*
Date of Birth*
Date Format: DD slash MM slash YYYY

Gender*
Occupation*
Address 1
Address 2
Town/City*
Country*
Contact No.
Email*

Are you a resident or citizen?*
Of which country are you a citizen?
Are you a politically exposed person?*
Please provide further details
Total Policyholders

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INSURANCE DETAILS
Is the risk address same as your address?*
Address 1*
Address 2*
Town/City*
Country*
Period of Insurance
From:*
Date Format: DD slash MM slash YYYY
Upto:*
Date Format: DD slash MM slash YYYY
Is there now or has there ever been insurance in respect of this property?*
- Yes
- No
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Other*
Is the property located in an area that has a history of flooding or within 100 feet of high water level?*
- Yes
- No
Please give additional details*
Is the property situated on reclaimed land, a hillside or steep incline?*
- Yes
- No
Please give additional details*
Has the property sustained any losses or were any claims made in the last 5 years?*
- Yes
- No
Please give additional details*
Have any Insurer, in respect of this property: *
Declined to insure you?
- Yes
- No
Please provide additional details*
Required special terms to insure you?
- Yes
- No
Please provide additional details*
Cancelled or refused to renew your insurance?
- Yes
- No
Please provide additional details*
Increased your premium
- Yes
- No
Please provide additional details*
Is the property mortgaged?
- Yes
- No
Please give details of mortgagee*

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THE PROPERTY
Please describe the premises
Please give details*
Number of storeys*
Is this property likely to be unoccupied for more than 30 consecutive days in any given year?*
- Yes
- No
Will the property be used solely for residential purposes?*
- Yes
- No
Please describe fully the usage of the property*
Is the building occupied solely by you and your family?*
- Yes
- No
Please describe who will be occupying the building*
What is the main construction of the walls?*
Other*
What is the main material of the roof?*
Other*
What is the main material of the floors?*
Other*
What is the main construction of the internal partitions?*
Other*

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CONTENTS
Do you require cover for contents?*
- Yes
- No
Signature*
- Type-in Signature
- Digital Signature
Signature*
Please sign here*
Contents to insure
Press Control/CMD on your keyboard and do multiple selection
*No one item can exceed 5% of the Sum Insured (Value) of its Category (General Contents, Jewellery, Electronics).
Bedroom Suite*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Books*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Cabinets/Shelves*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
China/ Ornaments*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Clocks/Antiques*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Clothing/Footwear*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Desks*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Crockery/Glassware*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Dining table/ Tables*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Dishwasher*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Food mixer/ Processor*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Lawnmower*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Light fittings/ Lamps*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Microwave*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Paintings/ Artwork*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Patio Set*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Rug/ Curtains/ Drapes*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Silverware*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Sofa Set*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Standing Fans*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Stove*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Toys*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Washing machine/ Dryer*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Bracelets*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Earrings*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Necklaces*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Watches*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Rings*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Fridge/ Freezer*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Stereo Systems*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Home Theaters*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Occupants
Content Title*
Date of Purchase*
Date Format: DD slash MM slash YYYY

Sum Insured*

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Signature*
- Type-in Signature
- Digital Signature
Signature*
Please sign here*
Signature (Second Policyholder)*
Signature (Second Policyholder)*
Signature (Third Policyholder)*
Signature (Third Policyholder)*
Signature (Fourth Policyholder)*
Signature (Fourth Policyholder)*
Declaration*
- By signing or printing my name, I agree that this signature will be an electronic representation of my signature for all purposes when I use them on this document, just the same as a wet ink signature on paper.
Date*
Date Format: DD slash MM slash YYYY
Branches
If this form is being completed at a Gulf Branch, please select the name of the Branch
Would you like this form to be e-mailed to an additional person?*
- Yes
- No
Email*

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--- GENERAL CONTENTS
Bedroom Suite
Books
Cabinets/Shelves
China/ Ornaments
Clocks/Antiques
Clothing/Footwear
Crockery/Glassware
Desks
Dining table/ Tables
Dishwasher
Food mixer/ Processor
Lawnmower
Light fittings/ Lamps
Microwave
Paintings/ Artwork
Patio Set
Rug/ Curtains/ Drapes
Silverware
Sofa Set
Standing Fans
Stove
Toys
Washing machine/ Dryer
Other
--- JEWELLERY
Bracelets
Earrings
Necklaces
Watches
Rings
Other
--- ELECTRONICS
Fridge/ Freezer
Stereo Systems
Television Sets/ Home Theaters
Other

Homeowner’s Proposal Form

Step 1 of 6 - PROPOSER`S DECLARATION

PROPOSER DETAILS

Policyholder Details

Policyholder Details

INSURANCE DETAILS

Period of Insurance

Have any Insurer, in respect of this property: *

THE PROPERTY

CONTENTS