Electronic Equipment | Proposal

Personal Details

Risk Details

General Policy Details

Personal Details

Proposer Type

Bank Assurance Officer

Select Intermediary branch

Insurance Company

ID Type

ID Number

KRA Pin

First Name

Middle Name

Last Name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

Contact Details

Mobile No.

Telephone No.

Email Address

Postal Address

Postal Office

Town

County

Region

Earth Quake Zone

Physical Address

Which FBBI branch do you want to be served from?

Do you have a Fire Industrial from FBIA?

Period of insurance

Insurance Start Date

Insurance End Date

Risk Details

Particulars of Insurance

Location of equipment to be insured

Name of Building

Plot Number / LR. No.

Street / Road

City / Town

County

Financier Interest

1. Material Damage

Equipment

Make

Model

Serial Number

Year of Manufacture

Sum insured

Total sum insured of material damage

Do you want external data media?

1. External Data Media

Data media

Type

Quantity

Value

Expenses for reconstruction and restoration of information

Total Sum Insured

Do you want increased cost of working (ICOW)?

Increased Cost of Working (ICOW)

Equipment Insured	Limit of Indemnity		Sum Insured
	Per Day	Per Month
Rental of Substitute Electronic Data Processing Equipment
Personnel Expenses
Expenses for Transport of Materials
			Total Sum Insured

Do you require indemnity period cover?

Note : Default minimum time excess is 2 days.

Do you require time excess?

Is there a risk of flooding or water damage?

Are dangerous materials used in the vicinity

Condition of the Equipment

Is the equipment new?

Was the equipment obtained ex works, that is, were all costs from the seller’s premises borne by you?

Is the Air Conditioner:

(Any one can be selected at one time)

Pressurized?

Recommended by manufacturer of the equipment?

Not necessary

Others

Fire Prevention Measures

Fire-resistant walls and ceilings

Fire-resistant wall and ceiling openings (door)

Smoke-proof and fire-resistant

Smoke and heat venting systems

Others

Fire Detection Facilities

Smoke Detectors

Heat Detectors

Optical Detectors

Push Button Fire Alarms

Fire Alarms by Telephone

Supervision by Guards

Others

Fire-fighting facilities

Portable Fire Extinguishers Filled with:

CO²

Halon

Powder Water

Wall Hydrants connected with:

Hose and Steel Pipe

Sprinklers

CO² Flooding System

Halon Flooding System

Others

Note : The following type of equipment’s can be insured. Computers and allied accessories, Auxiliary equipment like UPS, Voltage stabilizer, Medical, Bio medical, equipment e.g. Laboratory equipment, X-ray Machine, Ultrasound machines, MRI, CAT scan Machines, Audio/visual equipment, Electronic control panels, Telecommunication and navigational equipment, Electronic equipment for research and material testing and similar equipment.

Maintenance

Is the equipment maintained in accordance with the manufacturer’s instructions?

Is there a valid Maintenance Contract in place?

Quality of Staff

Have all operators been trained to handle the equipment?

General Policy Details

Are you now or have you ever been insured for this type of policy ?

Has any insurance company ever

Declined your proposal ?

Cancelled or refused to renew your policy?

Required an increased premium or imposed special conditions?

Declined your claim?

Insurance and Loss History

Please provide below information on any insurance claims you have reported in the last 5 years

Type of loss

Year of Incident

Claim Amount/ Value

Add Loss

DECLARATION | Please Read Carefully *

I/ We do hereby declare that the above answers and statements are true and that I/ We have withheld no material information regarding this proposal. I/ We agree that this declaration and the answers given above as well as any proposal or declaration or statement made in writing by me/ us or anyone acting on my/ our behalf shall form the basis of the contract between me/ us and the Company. I/ We further agree to accept indemnity subject to the conditions in and endorsed on the Company’s policy.

CREDIT INFORMATION | Please Read Carefully *

I/we do hereby confirm that I/we have authorized Family Bank Insurance Agency to share my/our credit information and to access my/our credit profile from Credit Reference Bureau (C.R.B)

Electronic Equipment Proposal

Personal Details

Contact Details

Period of insurance

Risk Details

Particulars of Insurance

Location of equipment to be insured

1. Material Damage

Do you want external data media?

1. External Data Media

Data media

Do you want increased cost of working (ICOW)?

Increased Cost of Working (ICOW)

(At least one must be choosed)

Condition of the Equipment

Is the Air Conditioner:

(Any one can be selected at one time)

Fire Prevention Measures

Fire Detection Facilities

Fire-fighting facilities

Portable Fire Extinguishers Filled with:

Wall Hydrants connected with:

Maintenance

Quality of Staff

General Policy Details

Has any insurance company ever

Insurance and Loss History

DECLARATION | Please Read Carefully *

CREDIT INFORMATION | Please Read Carefully *