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1. PROPOSER DETAILS    
(a) NAME OF PROPOSER and Subsidiary and/or affiliated companies
(b) STATE CONTACT NAME and ADDRESS of the premises to which the policy is to apply
(PLEASE COMPLETE A SEPARATE FORM FOR EACH ADDRESS)
POST OR AREA CODE:  COUNTRY: 
TEL:  FAX:           EMAIL:
MOBILE:     WEBSITE:
(c) WHEN DID YOU OR YOUR COMPANY COMMENCE TRADING?

2. STOCK VALUES    
(a) WHAT IS THE AVERAGE TOTAL VALUE OF YOUR OWN STOCK, MONEY AND
GOODS IN TRUST USED IN THE CONDUCT OF YOUR BUSINESS?
(b) WHAT IS THE ESTIMATED MAXIMUM VALUE OF STOCK, MONEY AND GOODS IN
TRUST AT ANY TIME?
(c) SEASONAL INCREASE    FROM   TO  SUM INSURED INCREASED
BY AN ADDITIONAL
ADDITIONAL INFORMATION

3. OUTSIDE LIMIT      
WHAT LIMIT IS REQUIRED FOR ANY ONE LOSS FOR PROPERTY (STOCK, MONEY OR GOODS IN TRUST) ELSEWHERE THAN AT YOUR PREMISES
(a) WITHIN THE ANTWERP DIAMOMD AREA DEFINED AS SCHUPSTRAAT, HOVENIERSTRAAT, KOORTE HERENTALSTRAAT, APPLEMANSTRAAT, VESTINGSTRAAT AND BOURSE SIDE OF PELIKAANSTRAAT ?
(b) WHAT LIMIT IS REQUIRED FOR ANY ONE LOSS FOR PROPERTY ELSEWHERE IN BELGIUM ?
(c) WHAT LIMIT IS REQUIRED FOR ANY ONE LOSS FOR PROPERTY ELSEWHERE IN THE WORLD ?
(d) HOW MANY DAYS IN TOTAL FOR YOUR COMPANY WILL YOU REQUIRE FOR THESE TRANSITS          ADA    BELGIUM  OTHER 
(e) WHAT LIMIT IS REQUIRED IN RESPECT OF MEMO/APPROBATION WITHIN ADA? MAXIMUM TO ANY THIRD PARTY
    		MAXIMUM IN ALL AT ANY TIME
TO ALL THIRD PARTIES     

4. SENDINGS    
(a) WHAT IS THE ESTIMATED ANNUAL VALUE OF GOODS DESPATCHED BY AN APPROVED CARRIER SUCH AS REGISTERED POST, AIRFREIGHT OR PERSONAL CONVEYANCE ?
(b) WHAT IS THE ESTIMATED ANNUAL VALUE OF GOODS DESPATCHED BY AN ARMOURED CARRIER SUCH AS BRINKS MAT, MALCA AMIT, REGENCY SHIPPING LTD OR FERRARI WITHOUT EFFECTING INSURANCE WITH THE CARRIER ?
(c) WHAT IS THE ESTIMATED ANNUAL VALUE OF GOODS DESPATCHED BY AN ARMOURED CARRIER SUCH AS BRINKS MAT, MALCA AMIT, REGENCY SHIPPING LTD OR FERRARI FOR WHICH ONLY CONTINGENCY COVER IS REQUIRED IN THE EVENT THAT THE ARMOURED CARRIER'S INSURANCE FAILS ?

5. SUPPLEMENTS  
DETAIL BELOW ANY OTHER LIMITS OR TERMS YOU WISH TO INCORPORATE INTO YOUR QUOTE

6. ADDITIONAL INFORMATION      
(a) HOW MANY EMPLOYEES HAVE YOU ?
(b) STATE YOUR APPROXIMATE ANNUAL SALES TURNOVER. THIS IS MANDATORY IF EITHER LOSS OF PROFITS, PUBLIC/PRODUCTS OR EMPLOYERS' LIABILITY IS REQUIRED
(c) ARE YOU CURRENTLY INSURED ?
(d) IF YES WITH WHOM ARE YOU INSURED ?
(e) ON WHAT DATE DOES YOUR POLICY EXPIRE ?
(f) ARE YOU CURRENTLY INSURED OR HAVE YOU EVER BEEN INSURED THROUGH GJIS IN THE PAST?

7. LOSSES      
(a) HAVE YOU EVER SUSTAINED A LOSS OR LOSSES UNDER THE TYPE OF POLICY NOW PROPOSED WHETHER INSURED OR NOT ?
(b) IF YES GIVE STATEMENT COVERING THE PAST FIVE YEARS WITH PARTICULARS, INCLUDING THE AMOUNT OF EACH LOSS AND, IF INSURED WHETHER PAID IN FULL OR OTHERWISE.
PLEASE INDICATE THE LIKELY COST FOR INSURANCE BASED UPON THESE PARTICULARS. I/WE UNDERSTAND IT IS A GUIDE ONLY AND THAT IT DOES NOT BIND ME TO COMPLETE ANY INSURANCE AND THAT ANY INSURANCE WE EFFECT IS SUBJECT TO THE COMPLETION OF A FULL PROPOSAL FORM SHOULD WE WISH TO PROCEED.
  I HAVE READ AND ACCEPT PRIVACY STATEMENT AND AGREE WITH TERMS AND CONDITIONS FOR USING THIS WEBSITE.
FOR AND ON BEHALF OF:   DATE:
   CLICK HERE TO SUBMIT YOUR DETAILS   
EMAIL: insurance@gjis.ie WEB: www.gjis.ie
 

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