QUESTIONNAIRE/APPLICATION

HOME AND CONTENTS INSURANCE

The Applicant/s

Name (s) of Insured in full if insufficient space or if policy in name of company or other entity, please attach details.

1)     Civil Code/DOB

2)    Civil Code/DOB   

Company ID   

Postal Address for Notices   

Period of insurance From    To   

Third parties interest in the property insured   

Information about the home and contents

Site of home

1) How is the home occupied

By you as owner By a tenant By you as a tenant/renting (not sharing)

Vacant home (unoccupied more then 60 days) Other, give details

Address of the property insured

2) Type of home

Freestanding house Home unit /Flat Other

3) Construction details

a) Walls Bricks Reinforced concrete Wood Other

b) Roof Tile Iron Colourbond Other

Size of home sq.m2  Year of construction

4) Condition of home:

Good Average Needs maintenance &/or repairs, give details

5) Has the home been rewired? Yes No if “Yes”, year

replumbed? Yes No if “Yes”, year

6) Does the home have any of the following protection?

Deadlocks on all external doors Yes No

Bars on all accessible louver windows Yes No

Professionally Installed local alarm Yes No

Professionally Installed Monitored alarm SOT Yes No

24 hours concierge/security person Yes No

Smoke detectors Yes No

Water sprinklers Yes No

7) Have you or anyone living permanently with you:

a) been refused insurance; been declined renewal of insurance; been quoted an increased premium or

had any special terms or conditions imposed? If “Yes”, give details

b) been charged or convicted during the last five years of arson or any offence involving actual or threatened damage to property; any criminal act fraud; theft; drugs; or dishonesty of any kind? Yes No

If “Yes”, give details

c) suffered any loss during the past five years from any of the events against which you wish to insure Yes No

If “Yes”, give details

d) Are there any exceptional circumstances you know about, which are relevant to our decision to insure Yes No

you and on what terms? If “Yes”, give details

Please state the name of your previous home and contents Insurer

Expiry date of insurance

Limits of Liability

How much do you want to ensure for?

  Property type Sum insured Coverage* Deductible option Premium Discount Due total
Section 1 Home
Section 2.1 Unspecified Contents**
Section 2.2 Specified Contents
Section 3 Legal Liability
  TOTAL

*Coverage you can choose of the list below:

(a) Fire or explosion

(b) Storm (including cyclone or hurricane) and/or rain, which may be accompanied by snow, sleet or hail

(c) Lightning or thunderbolt

(d) Earthquake

(e) Flood (inundation of normally dry land by water from any watercourse, lake, canal, dam or reservoir)

(f) Theft

(g) Malicious acts including arson

(h) Bursting or leaking of apparatus, tanks or fixed pipes used to hold or carry liquid of any kind

(i) Impact by: vehicle, an aircraft or a waterborne craft,space debris or debris from an aircraft, rocket or satellite ,an animal, a falling tree or part of a tree,a mast or a television or radio aerial that has broken or collapsed.

**There are limits to the amount we pay on certain items. These items are limits set out in the policy under How we will pay.

You may obtain higher limits by specifying any of these items below. We pay up to the amount specified.

Specified Contents e.g. antiques or works of art , jewellery, watches or collections of any kind.

Please list the contents items you wish to specify and provide as much identification as possible e.g. serial numbers,

valuations, receipts.

Item Sum Insured
Total

Deductible options

  Deductible amount* Applicable discount
Option 1 50 BGN 5%
Option 2 100 BGN 7%
Option 3 200 BGN 10%
Option 4 No deductible except stated in the wordings  

* Deductible amount from each and every loss

Options you can choose for additional premium

The following options may be obtained for an additional premium:

Temporary accommodation Yes No Premium

Automatic reinstatement of sum insured Yes No Premium

Storm damage to outbuildings and improvements Yes No Premium

Premium Payment Plan:

1) in full 2) in instalments (number)

You should keep your policy in a safe and convenient place, and also keep receipts or other evidence of ownership

and value of items you have specified here and other items or significant value.

Signature and declaration

I, the undersigned, hereby declare on the basis of all facts known to me, that the information provided by me in relation with this

application is true and I have not concealed any material circumstances related to this insurance. I understand that non-disclosure

or incomplete or incorrect disclosure of material circumstances will entitle the insurer to reduce the amount of indemnity or

to refuse to pay any indemnity.

Remark: “Material circumstances” are those circumstances, which can be expected to have influence over the decision of the

insurer to assess my application. If you are doubtful about what is the meaning of “Material circumstances”, you should consult

your insurance intermediary or your solicitor.

I agree with the General conditions of QBE Insurance (Europe) Limited Sofia Branch for Home and Contents Insured

Events Policy

Date

Applicant's Title

Applicant's Signature