| QBE Insurance (Europe) Limited - Sofia Branch |
| Questionnaire for Household Insurance |
| Insured details |
| Civil ID for Bulgarian citizens or date of birth for others: | Civil ID: or Date of birth: (day, Month, Year) |
| Name: | |
| Address: | Postal/ZIP code: City: Full Addres (incl. Street No., Block, Entrance, Ap. No.): |
| E-mail*: | |
| Policy details |
| Policy start date: | As soon as possible Date: (day, Month, Year) |
| Bank beneficiary: (In case home is mortgaged in favor of a bank and the bank will be beneficiary for the policy, please enter bank's details) |
| | BIC:
or
Name: |
Representations
(In order to keep the questions we need to ask to a minimum, we have prepared certain representations to be made by you. Please take the time to read through these representations, as they will form part of your home insurance contract) |
YOUR HOME:
- Is maintained in a good state of repair
- Is built of brick or concrete and roofed with tile or concrete
- Is fitted with a key operated, metal locking device to all opening ground floor, basement and other accessible windows
- Has not been damaged by flood and not in an area liable to flood*
- Has not been affected by subsidence, heave, landslip or structural movement and is not in area subject to subsidence**
|
YOU AND ANY ADULT LIVING WITH YOU:
- Have never had home insurance refused or declared null and void
- Have never been convicted of any criminal offence (other than motoring convictions) or have any prosecutions pending
- Have not suffered more than 1 loss, damage or liability (whether insured or not) related to your home during the last two years
- Have not suffered a burglary within the last 12 months
- Have never been threatened
|
Invalid representations:
(if any of the representations above are not valid for you or your home, please state the valid here)
* We would consider that your home is in an "area liable to flood" if a territory within a distance of 250 m. or less of your home has been affected by river or coastal flooding. ** We would consider that your home is in an "area subject to subsidence" if any property within a distance of 100 m. or less of your home has been affected by subsidence.
|
| Main Details of Home |
Type:
(please select one from the listed)
| 1. Apartment - an individual object of title designated for residential purposes constituting part of a condominium building
2. House
|
Occupancy:
(please select one from the listed)
| Home is occupied permanently (primary residence)
|
Location:
(if different from the address of the Insured)
|
Postal/ZIP code: City: Full Addres (incl. Street No., Block, Entrance, Ap. No.):
|
Subject of Insurance and Sum Insured |
Currency:
(please select a currency) | BGN EUR |
Subject Sum Insured:
|
| Home* | |
| Contents* | |
| Liability |
50,000 BGN / 25,565 EUR
100,000 BGN / 51,130 EUR
200,000 BGN / 102,260 EUR
|
Additional Details of Home
(To receive premium discounts, please mark the statements relevant to the home) |
Year Home Built:
(please select one from the listed, if relevant)
| After 1987
Between 1956 and 1987 (inclusive)
|
Age of Water and Sewage Pipes and Electric Installation:
(please select one from the listed, if relevant)
| Less than 11 years
Between 11 and 20 years (inclusive)
|
Fire Protection:
(please check the relevant)
| Distance to Fire Brigade approximately less than 15km
Smoke detectors or fire alarm system is installed
|
Only for house, distance to water (river, lake, sea, dam):
(please select one from the listed, if relevant)
| Approximately more than 100 m
Between 50m and 100m
|
Security:
(please check the relevant)
| Only for Apartment, the home is on the 2nd floor or higher
Professionally installed monitores security system with respond time up to 10 minutes
24 hours guards and video monitoring
|
| Imortant note: Once the insurance quote has been obtained and accepted by you please make sure that all bank charges are covered by you to make it possible for the payment to arrive into the insurance compnay's bank account to the required amount. Thank you. |
| | Send |
