Agostini Insurance Brokers - Insurance Calculator

Surname

First Name

Middle Initial

Name of Proposer *

:

Mailing Address *

:

Telephone Contact (Home) *

:

Telephone Contact (Work)

Telephone Contact (Mobile)*

Email *

:

Are you employed by a Bank? *

:

Yes No

Over 60 *

:

Yes No

Address of Premises to which Insurance is to apply *

:

Subject of Insurance

For the purpose of this Insurance the Sums Insured must represent the Replacement Costs of the Property.

Type of Quotation *

Mortgage

:

First Citizens Bank Limited

Republic Bank Limited

Republic Bank Limited Employee

Other

:

Furness Anchorage General Insurance

GTM Insurance Company Limited

Sagicor

Guardian General Insurance Limited

Building (Excluding subsidence and landslip)

:

$

Retaining walls

:

$

Swimming Pool

:

$

General Contents

:

$

Electronic Equipment

:

$

Jewellery

:

$

Computer Desktop

:

$

Computer Laptop

:

$

Camera

:

$

Cellphone

:

$

Construction of Building (Material used for Construction)

External Walls *

:

Roof *

:

Floors *

:

No.of Storeys *

:

1 (One) 2 (Two) 3 (Three)

Is/are the building(s) in a good state of repair and will they be kept so?

:

Yes No

Has any insurer, in respect of the risks to be insured

a) Decline to insure you?

:

Yes No

b) Cancelled or refused to renew?

:

Yes No

c) Increased your premium at renewal?

:

Yes No

Is the building *

:

Private House Flat Townhouse Apartment

Premises occupied by

:

Insured Tenents

How many days (consecutive) will the premises be left without an inhabitant in any one year?

:

Will the Premises be used for any profession, trade &/or Business

:

Yes No

If Applicable Mortgagee: 1st

:

(Name & Address) 2nd

:

Have you had ay claims/ losses in respect of the risks to be insured in the past five (5) years?

:

Yes No

Is the cover against the peril of Collapse due to Subsidence and Landslip required?

:

Yes No


	Disclaimer:

	Your privacy is important to us. Agostini Insurance Brokers Limited does not rent, sell, or share personal information about you with other people or non-affiliated companies.

	All quotes from Agostini are valid for 30 days following the date of generation.

	Agostini Insurance Brokers accepts no liability for quotations generated as QUOTATIONS ARE SUBJECT TO CHANGE.

	For more information please contact, one of the friendly and courteous members, of our Personal Lines Department.

Accept Decline

I do hereby declare that the above answers and statements are true and that I have withheld no material information regarding this Proposal.