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Proposal No.
NATIONAL
INSURANCE CORPORATION LTD
(INCORPORATED
(a)
(b)
(d)
(e )
Please state:
(a)
Address and Description of Premises containing
Property to be insured (say whether House, Shop, ..........
Warehouse, Factory, &c.) ...
(b)
How long occupied by you? ....... years
(a)
(b)
(b)..........
(a) .............
(b) .............
(c) ...............
(a)
(b)
(c)
(a)
(c)
8
(iv).
(a) ..........
(b)
(i) ..................
(ii).
(iii)
(a) .................
(b) ................
(c) .............
2
9
(b)
10
11
12
....................
...................
(a)
(b)
13
14
(a) .................
(b) ................
State
(a) ................
(b) ...............
(a) ...............
(b) ..............
(a) ...............
(b) ................
(c) ................
15
16
...
...
On Gold and Silver plate, Jewellery, Personal
(f)
...
Ornaments, Watches, Trinklets and Furs
On the following articles not other wise specified:
..........................................................
(g)
...
.
...
.
...
First Loss Sum to be Insured Ush.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Annual Premium
...
(Furniture, Pianos and Organs excepted) shall be deemed of
Odd Time
...
greater value than 5 percent of the total sum insured under
First Premium
...
such items, unless specifically mentioned and separately
insured
Period of Insurance from Until
Unless specifically included the Policy will not cover the Loss of Money, or Secruties for Money. In any form.
No one article included in Items (e) or (f) in this schedule
3
I/We hereby propose to effect an insurance with the NATIONAL INSURANCE CORPORATION, and do
warrant the truth and corrections of all the foregoing statements and declare that no material information has been
withheld.
I/We agree that this proposal and declaration shall form the basis of the contract between me/us and the said
Company, and I/We am/are willing to accept the Policy and be bound by all the terms, provisions and conditions
thereof, and to pay the premium thereunder when called upon to do so.
Date ................ Signature of Proposer ...............
AGENT'S REPORT. - I have known the proposer for .... years, believe him/them to be of good
character and repute, I recommend acceptance of this Proposal.
Agent's Signature .................. Address ...............
No liability is accepted by the Company until the issue of the Policy and the payment of the premium, or the
issue of a duly authorised cover note by the Company.
Give full details in full for items proposed.
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