Deterioration Of Stock Insurance

Personal Details

Risk Details

General Policy Details

Personal Details

Proposer Type

Are You a Shareholder?

Intermediary

Agent Name/Code

Binder

ID Type

ID Number

TIN Number

Proposer First Name

Proposer Middle Name

Proposer Last Name

Is there any Care of/Account of/and?

Please specify name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

Is the insurance being purchased for self? (if no, state your details)

First Name

Middle Name

Last Name

Applicant Contact & Other Details

Contact Details

Mobile No.

Telephone No.

Fax No.

Region/City

Zone/Sub City

Woreda/District

Kebele

P.O. Box No.

H.No.

Email Address

Which Berhan Insurance S.C. branch do you want to be served from?

Physical Address

Do you have a Machinery Breakdown from Berhan Insurance S.C.?

Period of Insurance

Insurance Start Date

Insurance End Date

General Policy Details

Are you now or have you ever been insured for this type of policy ?

Has any insurance company ever

Declined your proposal ?

Cancelled or refused to renew your policy?

Required an increased premium or imposed special conditions?

Declined your claim?

Required you to carry the first portion of any loss?

Insurance and Loss History

Please provide below information on any insurance claims you have reported in the last 3 years

Type of loss

Year of Incident

Claim Amount/ Value

Add Loss

DECLARATION AND CONSENT | Please Read Carefully *

I the undersigned declare that the vehicle(s) described (is/are) in good condition and will continue to be maintained and I hereby warrant that the above statement and particulars are true and I hereby agree that declaration shall be deemed to be of a promissory nature and effect and the basis of the contract between me and the Company and that I have not withheld any important information which should be communicated to the Company and that I am willing to accept a policy subject to the terms, conditions and exceptions therein and to pay the premium agreed upon.

CREDIT INFORMATION | Please Read Carefully *

I/we do hereby confirm that I/we have authorized Berhan Insurance S.C. to share my/our credit information and to access my/our credit profile from Credit Reference Bureau (C.R.B)

Deterioration Of Stock Insurance Proposal

Personal Details

Contact Details

Period of Insurance

Building Details

1. Location Details

Building Details

Cold Storage House particulars:

Particulars of Refrigerant facilities:

What is the type of refrigerant used?*

Pipes carrying refrigerant are on the?*

Who carries out supervision?*

Maintenance Carried Out?

Maintenance Carried Out by?*

Refrigerating plant details:

Control and Alarm systems

Controlled Atmosphere Storage

Power Supply

Power supply:

Laid:

Schedule of Goods to be insured

Do you require the following extensions

General Policy Details

Has any insurance company ever

Insurance and Loss History

DECLARATION AND CONSENT | Please Read Carefully *

CREDIT INFORMATION | Please Read Carefully *