APPLICATION FOR FIRE & BURGLARY INSURANCE All information entered is strictly kept confidential.

Name of  Proposer:
Address of Property:
Business/Trade or Occupation carried therein:	E.g. (If it is a two storey building) Downstairs: Used car dealer Upstairs: Office
Period of insurance required:
Construction of building: (Delete where not applicable  or type for others)	Roof: Tiles/concrete/asbestos/others All external walls: Brick/plank/zinc/others Floor: Upstairs concrete/plank Downstairs: concrete Age of building: ? Number of storeys: ?
What kind of lighting and heating apparatus is used?
	AMOUNT TO BE INSURED IN MALAYSIAN RM
(1) On building:
(2) On machinery and utensils:
(3) On stock in trade consisting of:	E.g. Finished product...RM Unfinished product...RM
(4) On rental:
(5) On furniture, fixtures & fittings:
(6) On household goods & personal effects:
(7) On removal of debris:
(8) On architects, surveyors & consultant engineering fees:
(9) On others (Please specify):
TOTAL SUM INSURED:	Item (1) to (9)
Is the building detached?	Yes    No
If adjoining, construction and occupation of adjoining premises:	E.g. Same construction. Sundry shop on one side and Motor-cycle repair shop the other side.
Additonal perils required: (Delete and type NIL, if not  required)	E.g. Riot, Strike & Malicious Damage/Earthquake, volcanic eruption/Storm & Tempest/Flood/Explosion/Aircraft Damage/Impact Damage (excluding insured's own vehicles/ Impact Damage by falling tree or branches.
Burglary Insurance required?	Yes    No
Amount of  Burglary coverage:
Contact tel. number: Email address: Person to contact:
Please check to see that your form is duly completed before you submit.  Thanks.
If you have any query, please use our  Enquiry  form,  E-mail  us  or call  012-5158027