APPLICATION FOR HOUSEOWNER/HOUSEHOLDER INSURANCE (Private dwelling only)  All information entered is strictly kept confidential.

Name of Proposer:
Address of  Property:
Correspondence address:
Proposer's Date of Birth:	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ------ Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ------ Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 ------
Proposer's occupation:
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:
SECTION 1 - BUILDING	(Houseowner insurance)
On building including Extension & Renovation:
On architects, surveyors & consultant engineering fees:
Removal of debris:
SECTION 2 - CONTENTS	(Householder insurance)
*Total sum insured:
Please list only items or articles of greater value than 5% of the *Total Sum insured (Furniture, household appliances, radio and TV sets, piano and organ need not be listed).	.......................................RM .......................................RM
SECTION 3 - PERSONAL VALUABLES
Total sum insured (Replacement Cost):
Please list item with individual value in excess of RM2,000 (Receipts and/or professional appraisals are required) N.B. sum insured should not be greater than 50% of the Total Sum Insured under Section 2 - Contents	.....................................RM .....................................RM
SECTION 4 - PERSONAL LIABILITY
Limit required (Any one accident):	RM100,000       RM150,000       RM200,000
GENERAL QUESTIONS	(Must be answered - applicable to all sections)
a) Have you ever suffered damage or loss by any of the risks or liabilities you now wish to insure against?	Yes      No
If the above answer is "Yes", please give details.
b) In respect to any risk now to be insured, has any previous insurer refused to give cover, renew a policy or imposed any special terms?	Yes      No
If the above answer is "Yes", please give details.
c) Are there any existing insurance(s) in force covering the risk(s) you are now proposing?	Yes    No
If the above answer is "Yes", please give details.
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