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					                                                                                                                                                         FOR OFFICE USE ONLY
                                                                                                                                                         HSC
                                                                                                                                                         BROKER:




                                N.E.M. INSURANCE COMPANY
                                    (JAMAICA) LIMITED
                        HOUSEHOLD INSURANCE PROPOSAL FORM
A. PROPOSER DETAILS
                                First Name                                        Middle Name                                   Surname
1. Full Name of Insured
                                DD/MM/YYYY
2. Date of Birth                                   Place of Birth                               Nationality                                    TRN

3. Home Address

4. Mailing Address

5. Contact Information          Home:                Work:                        Cell:                      Fax:                   Email:

6. ID Information               Type & Number:                                                                 Expiry Date:

7. Occupation/ Business                                                                         Public Sector                          Private Sector
     All occupations must be fully described,
     Vague terms such as “Businessman” and “Director” are not acceptable and must be expanded
8. Place of Employment
    Name and Address
9. Have you or any relative or close associate been
    entrusted with prominent public functions in any     Yes      No           If yes, give details
    country?

10. PERIOD OF INSURANCE                                            From:                                            To:



B. ABOUT THE HOME
                                Apt#      Street                               Street #      Town/District                          Post office/Agency   Parish
 1. Property Address
 2. Give the following details of the home to be insured:

 a Will it be left unoccupied for any consecutive period of more than 30 days?                  Yes          No

        If yes, give details

 b Are the buildings in good condition and will they be so maintained?                          Yes          No

        If no, give details

 c i.        Are any business goods stored in the home?                                         Yes          No

      ii.    Does it contain a business or profession of any kind?                              Yes          No

    If yes, give details
   Has any loss or damage been sustained in the last three years on this
 d property and/or by you?                                                                      Yes          No

        If yes, give details
                                                                    If yes, state distance
 e Is this a Waterfront property?     Yes     No                           from waterline.
 f Does it have the following Security Features on            I.    Burglar Alarm
                                                             II.    Burglar Bars
   the premises? Tick all that apply                        III.    Watchman
                                                            IV.     Panic Buttons
                                                             V.     Dogs
                                                            VI.     Guards                      State Security Company
                                                           VII.     Gated Community
                                                           VIII.    Neighborhood Watch
                                                            IX.     Extinguishers
                                                             X.     Smoke/Heat Detector
                                                            XI.     Hurricane Shutters
                                                           XII.     Other                       If “Other Please specify
 g Is it (please tick as appropriate):
   i. A self contained home such as Private Dwelling House, Townhouse,
       or a self contained flat with a separate entrance exclusively under the
       sole control of yourself or your immediate family?                                 Yes       No
   ii. An apartment or rooms to which occupants other than your
       immediate family have access.                                                      Yes       No
 h Is it (please tick as appropriate):
      i.     Owner Occupied
      ii.    Rented out to someone else?
      iii.   Rented by you from somebody else?                                    If so, give details
      iv.    Rented out on short term basis i.e. less than 6 months               If so, give details
      v.     All or part of a strata plan?                                        If so, give details
      vi.    All or part of a building which exceeds five storeys?

 i    Is the subject of a mortgage? Yes       No        Is so, state Name and address of Mortgagee
      Is it exposed to any abnormal hazard by (please tick if
      applicable)                                                        If so, give details
         i. Flooding?                                                    If so, give details
        ii. Landslip?                                                    If so, give details
       iii. Hurricane?                                                   If so, give details
       iv. Earthquake?
 j       v.  Any other hazard?                                           If so, give details

 k Has any insurer refused to insure you or required special conditions or precautions?                        Yes         No

     If so, give full details
C. CONSTRUCTION
     1. What is your home built of? (Tick where                     WALLS                                              ROOF
     appropriate):                                 Block and Steel                              Reinforced Concrete (either poured or precast)
                                                   Precast Concrete                             Cement, Spanish & Clay tile
                                                   Spanish walls (stone + mortar)               Slates
                                                   Nog                                          Zinc Sheet
                                                   Brick                                        Alu-Steel
                                                   Cut-stone                                    Corrugated asbestos
                                                   Timber                                       Decra-bond, Mastic –tile
                                                   Other (Specify)                              Timber Shingles
                                                                                                Timber sarking covered with felt and/or paroid.
                                                                                                Aluminum Sheet or shingles
                                                                                                Continuous aluminum (in any profile)
                                                                                                Fiberglass shingles
                                                                                                Thatch
                                                                                                Other (Specify)

D. SUMS TO BE INSURED
             BUILDINGS AND STRUCTURES:                  $                CONTENTS
a)     The Main Building                                                 Including all of the household goods and personal belongings of the
b)     Domestic outbuilding                                              proposer or any member of the family residing at the dwelling above.
c)     Boundary walls (excluding retaining walls)                                                                       $
d)     Gates, fences and hedges                                          NOTE:
e)     All landlord fixtures and fittings                                   1.      The sums insured must be based on the cost of rebuilding or
f)     Solar water heaters                                                          replacement and not the market value. There should be no
g)     Air conditioning units                                                       deduction for depreciation because most claims under this policy
h)     Awnings                                                                      are settled on a Replacement basis.
i)     Paved areas                                                            2.    NEM recommends that a professional valuation be used as the
                                                                                    basis for establishing the sums insured. This is the most reliable
j)     Gazebos
                                                                                    means of producing an adequate sum insured.
k)     Radio and television aerials and antennas (other
                                                                              3.    You must sign the attached statement regarding underinsurance,
       than satellite dish)
                                                                                    as required by the Financial Services Commission.
l)     Retaining Wall(s)/Sea Wall(s)
m)     Generator
n)     Satellite dish (external)
o)     Swimming Pool including pool deck, pump
       house, related pipes and fixed pool accessories.
p)     Water Tanks
q)     Other – please describe

E. VALUABLES AND ALL RISKS
SPECIFIED ITEMS:                                               ALL RISKS:
List below all items which are included in the Sum to be       List below all individual items which you wish to insure against Accidental Loss or
insured under Contents                                         Damage, in addition to the standard perils insured under this policy.
a. jewellery, paintings, sculptures, cameras, curios and              ITEMS TO BE INSURED                  SUM INSURED              Jamaica (JAM)
      the like and                                                (make, model, serial # must be                                        only or
b. Audio and Video equipment, televisions, computers                included where appropriate)                                       Worldwide
      and accessories, external and internal components of                                                                              (WW)?
      satellite receiving system, C.B. Short-Wave and two-       PORTABLE ITEMS:
      way radio systems etc.                                     Jewellery
which are individually of a value greater than 5% of the           1.
total sum insured on the contents?                                 2.
                                                                   3.
Note that the limit for any one item is 5% of the Contents       Eye glasses and Contact Lenses
Sum Insured unless it is specified below.                          1.
        ITEM TO BE INSURED                        SUM              2.
     (make, model, serial# must be             INSURED             3.
      included where appropriate)
                                                                 Electronic and Photographic equipment including portable DVD players ,
                                                                 ipods etc*
                                                                   1.
                                                                   2.
                                                                   3.
                                                                  Sports equipment (excluding breakage of strings)
                                                                   1.
                                                                   2.
                                                                   3.
                                                                 Laptops and portable computer equipment*
                                                                   1.
                                                                   2.
                                                                   3.
                                                                 Cell Phones *
                                                                   1.
                                                                   2.
                                                                   3.
                                                                 FIXED ITEMS:
                                                                 Cups and Trophies
                                                                   1.
                                                                   2.
                                                                   3.
                                                                 Fixed electronic equipment including Personal Computer and peripheries,
                                                                 Satellite TV equipment (internal and external), TV, VCR, CD and DVD players etc.
                                                                   1.
                                                                   2.
                                                                   3.
                                                                 OTHER FIXED ITEMS:
                                                                   1.
                                                                   2.
                                                                   3.
                                                               Note:
                                                               1. Continue on a separate sheet of paper if necessary
                                                               2. The sums insured on ALL RISKS items must not be included in the Contents
                                                                      Sum Insured.
                                                               3. Excess: Items asterisked have a higher excess of 3%, $1,000 minimum, no
                                                                      maximum
                                                               4. Valuations or purchase receipts will be needed for all items insured over $5,000.

Does the total sum insured for goods insured under Specified Items and All Risks exceed 1/3rd of the Sum Insured on Contents?        Yes      No
Note that full details of the insurance cover are available in our specimen policy. Please ask for a copy
F. REFERENCES (Applicable only to Individual Proposers)
Name:                                                                         Name:


Address:                                                                      Address:


Telephone:                                                                    Telephone:




G. SOURCE OF FUNDS




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


 DATE                                                                         PROPOSER’S
              ------------------------------------------------------------     SIGNATURE      ----------------------------------------------------------------------




N.B. SUPPORTING DOCUMENTS REQUIRED
The following additional documents are required for corporate clients:

1.   Certificate of Incorporation (or similar document appropriate for a business
2.   Memorandum and Articles of Association (or Articles of Incorporation)
3.   Most recent annual return filed with the Registrar
4.   Name(s) and address(es) of owner(s) with shareholdings of 10% or greater
5.   Copies of ID documents for at least 2 directors/partners
The Financial Services Commission requires that you read and understand the following
“Notice to Insured”.




                          NEM INSURANCE COMPANY (JAMAICA) LIMITED

 Notice to Insured on the Nature and Effect of the Pro Rata Condition of Average (Average
Clause) in Accordance with the Insurance (Amendment) Regulations 2004; Regulations 123
                              (4) and (5) of the Insurance Act
                                                                                      HOC
                                                                                                                                            Please tick
                                                                                                                                       Appropriate Box:
                                                                                                                                           New Policy
                                                                                                                                           Renewal policy
To:




Name of Insurer


Name of Broker/Agent


Name of Insured


Policy Number


Policy Renewal Date


Please note that any property that is insured or to be insured under the policy mentioned above is subject to the pro rata condition of average
(average clause). This means that, under certain circumstances, if the property covered under this policy is, at the time of any loss or damage from
an insured peril, of greater value than the sum for which the property is insured, you will only be entitled to recover under this policy such proportion
of the loss as the sum insured under this policy bears in relation to the total value of the property. You are said to be under-insured property and so
a part of the insured loss will not be covered under this Policy. In this case, you are considered as being your own insurer for the part of your loss,
which is not covered under this policy.

For example, should you have a property which as a value of $10,000,000 and you decide to insure for $7,000,000 and you suffer a loss from an
insured peril, there are three possible scenarios depending on the size of the loss. The formula that is applied in each case as set out below.

          Sum Insured      x     Amount of the loss               =      Amount Recoverable
          Value                                       1                                   1


Example 1             Where the loss is less than value and less than Sum Insured:

                                Assume the loss is $5,000,000

          7,000,000 x          5,000,000   =          3,500,000
          10,000,000                       1                                 1

You will be paid $3,5000,000 or 70% of your loss less any deductible stated in the policy.


Example 2             Where the loss is less than value but greater than Sum Insured:

                                Assume the loss is $8,000,000

          7,000,000 x          8,000,000   =          5,600,000
          10,000,000               1                      1

You will be paid $5,600,000 or 70% of your loss less any deductible stated in the policy.

Example 3             Where loss is equal to value:

Should you have a total loss, that is, $10,000,000 then you will only receive the amount you insured the property for that is, $7,000,000.00 less any
deductible stated in the policy.

However, in respect of Home Owners Comprehensive policies on Private Dwellings and / or Contents contained therein, you may be
entitled to the full amount of the insured loss if the sum insured s equal to or more than_85%_of the value.

Please review the terms of your policy carefully, including checking on the adequacy of the sum for which the property is insured or is to be insured.
This will enable you to identify whether you are or will be under insured in a manner, which will cause the pro-rata condition of average to be applied.

This notice is given to you in fulfillment of the legal requirement to provide you with information on the nature and effect of the pro-rata condition of
average stated in your policy to be inserted in the policy of insurance mentioned above.
Please note that the extent to which the condition applies is governed by the terms of your policy.

          Dated the

          Signed:…………………………….
                      NEM INSURANCE CO. (JAMAICA) LTD.
                                                                                   HOC AV. 9/04

				
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