Preliminary insurance questionnaire│ Private client by Hiscox
This document forms part of your insurance contract
and must therefore be completed and signed prior to inception.
BROKER
Broker:
Mr / Mrs:
Phone number:
Fax:
/
Effective date:
/
Email:
Current insurer :
€
Current premium amount:
PROPOSER
Surname, first names of the insured:
If company (SCI, SARL etc.), please specify its corporate name:
Name of the legal representative of the company (if different):
Profession:
Marital status:
/
Birth date:
/
Address of correspondence:
Address of the building to be insured (if differs from the above address):
PREMISES
You are:
owner |
You are:
co-owner |
occupier |
tenant │
FLAT – Surface area:
Residence:
Situation: floor
bare owner
undivided owner
main - permanent |
secondary
m² | habitable outbuildings1 (maid’s room, studios...):
m² │ terraces:
cellar:
usufructuary│
non-occupier
m²
m² │ other unhabitable outbuildings (greenhouse, garage...):
│
of
under terraces │
m²
under maid’s room
OR
HOUSE – The residence is:
Buildings are built in:
a house │
stone │
a mansion │
wood │
a castle │
breeze block │
a chalet │
thatched roof
Developed area: (Main building, including adjoining outbuildings, cellars and attic):
habitable outbuildings1 (caretaker’s, guests’):
others:
m²
m²
m² │Surface area:
unhabitable outbuildings (pool house, garage...):
ha
If other address, please specify:
General global state:
excellent │
good │
medium │
repairs required | Year of construction:
Fixtures and fittings (wooden floor, ceilings, windows, doors, fixed elements of kitchens-bathrooms) │ Amount:
Works on-going or planned:
yes
€
no │ Duration / type :
The property is listed MH or inscribed ISMH:
yes
no │If yes, please specify:
The property is located in an aggravated risk area : (liable to flooding area ; overhanging a cliff, natural risk prevention plan on-going or
studied etc.):
yes
no
If yes, please specify:
The residence is rented out (in part, totally, annually, temporarily):
Farming
yes
Open to the public:
1
yes
no
€ │ Duration:
If yes, please confirm : The rental’s frequency:
Business purposes:
yes
│Amount of the rent:
no │ If so, please give details:
no
yes
no │ Guest houses:
yes
no │ Number of guest rooms:
Or unhabitable
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€
PROTECTION - PREVENTION
The residence is:
permanently caretaking (24h/24 and everyday):
partially │ Hours:
yes
no
│ Frequency:
no caretaker
Theft detection system:
related to:
with:
no │ Year of the installation:
yes
third party │
central station 24/7 |
annual maintenance contract │
The lowest access door are:
personal phone number
GSM transfer or other ADSL or line surveillance
armored │
full │
provided with multi-point locks │
provided with anti-angle clamps
The accessible openings (less than 2.50 m above the floor) are equipped with shutters, blinds, bars or burglary glazing:
yes
no | If no, please specify:
Safe-deposit box:
no │ Number:
yes
│Class:
│
sealed │
protected by contactor/volumetric
detectors
Fire detection system:
yes
no │
related to telemonitoring │ with:
Lightning conductor (paratonnerre):
(parasurtenseur):
yes
yes
annual maintenance contract
no │ Lightning arrester (parafoudre):
yes
no | Electric surge protector
no
Other security means:
…………
CONTENT, FINE ART, VALUABLES……………
TOTAL AMOUNT (B)+(C)+(D):
(B) GENERAL CONTENT
€
€
(furniture and daily objects, electrical appliance, linens…):
€
Personal effects:
(C) ART AND COLLECTION OBJECTS:
Including declared value
€
total amount :
single item max. amount:
€
Paintings
total amount:
€
single item max. amount:
€
Furniture
total amount:
€
single item max. amount:
€
Fragile objects*
total amount:
€
single item max. amount:
€
Others (wine, arms, etc.):
total amount:
€
single item max. amount:
€
* Porcelain biscuit, glassware, crystal, earthenware ...
Including agreed value, according to expertise or inventory attached, directed by :
reference:
date:
€
amount:
2/3
/
maximum unit amount:
/
€
(D) VALUABLES:
€
total amount:
€
single item max. amount:
(jewellery, watches, precious stone or semi-precious, precious metal items, platinum, gold, silver-gilt, sterling silver, plate etc.).
Including declared value
Whole world
total amount:
€
single item max. amount:
€
In the insured dwelling
total amount:
€
single item max. amount:
€
In bank safe
total amount:
€
single item max. amount:
€
Including agreed value, according to expertise or inventory attached, directed by:
reference:
/
date :
/
In the insured dwelling
total amount:
€ single item max. amount:
€
In a safe in the insured dwelling
total amount:
€ single item max. amount:
€
In bank safe
total amount:
€ single item max. amount:
€
Worldwide
total amount:
€ single item max. amount:
€
The required sums insured fits with the total value of all existing items:
If not, for which items:
content │
Other policy covering fine art:
yes
art and collection objects │
yes
no
precious objects
no │precious objects:
yes
no
Minimum standard excess per claim: 1 000€ or opt for a premium decrease choosing an excess per claim of:
2 000 € │
3 500 € │
7 500 € │
10 000 € │
€
Superior amount :
CLAIMS
Has there been losses or damages at the insured address in the last 5 years?
Date
Nature (Theft, water damage, natural catastrophes, etc.)
yes
no
Cost
€
Has there been losses or damages at others addresses ?: yes
them:
no
│ If so, please specify:
Causes have been
repaired
yes
no
€
yes
no
€
yes
no
│If so, give date, nature damages and cost for each of
Has any insurer cancelled any insurance for the proposer in the last 5 years ?: yes
no
If so, please give details about the cancellation:
DECLARATION
I undersigned
declare that all the information provided in connection with
this proposal, whether in my own hand or not, is true and that I have not withheld any material facts. I understand that non-disclosure or
misrepresentation of material fact will entitle underwriters to cancel this insurance since its inception (Article L 113-8 du Code des
Assurances) or to reduce the indemnity (Article L 113-9 du Code des Assurances). I understand that the signing of this proposal does
not bind me to complete the insurance but agree that, should a contract of insurance be concluded, this proposal and the statements
made in it and the information provided in connection with it will be relied upon by the underwriters in deciding whether to accept this
insurance and will form part of my insurance contract. Your signature is required to the project’s validation.
Done in
Date
/
/
Signature of proposer
Personal data protection: the information provided is treated in compliance with the French Law “n° 78-17 du 6 janvier 1978 relative à l’informatique, aux fichiers et aux libertés”: the insured is entitled to
have access to all personal data held by insurers with a right to correct.
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