| GA

PERSONAL DETAILS

RISK DETAILS

GENERAL POLICY DETAILS

Personal Details

Proposer Type

Intermediary

Select Intermediary branch

Binder

ID Type

Tax Pin Tax Pin

First Name

Middle Name

Last Name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

If insured name or other name

Quotation Validity Period

Contact Details

Mobile No.

Telephone No.

Email Address

Postal Address

Postal Office

Town

County

Region

Earth Quake Zone

Physical Address

Branch

Do you have Fire and Allied Perils policy from GA Insurance Limited?

Fire and Allied Perils policy number

Risk details

Insurance Start Date

Insurance End Date

Financier Interest

Name of the Chief Engineer

Name of Plant Manager

Nearest Railway Station / Airport

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 Claim History

DECLARATION AND CONSENT | 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.

I/We consent to Trident Insurance Company Ltd; (i) Collecting, using, disclosing and/or processing my/our personal data; and (ii) Transferring my/our personal data to their reinsurers and affiliated companies for the purposes of insurance as permitted by law.

CREDIT INFORMATION | Please Read Carefully *