AUREOL INSURANCE COMPANY LIMITED
INCORPORATED IN SIERRA LEONE
KISSY HOUSE, 54 SIAKA STEVENS STREET, FREETOWN
Mobile : +23278175175/+23233175175/+23288175175
Email : info@aureolinsurance.com
website : www.aureolinsurance.com
BRANCH OFFICE:
17 Tikonko Road
Bo
Mobile: +232(79)175175
FIRE INSURANCE PROPOSAL FORM
NAME OF PROPOSER IN FULL………………………………………………………………………………….
(If an unlimited company or partnership include full names of all parties)
PROFESSION OR OCCUPATION………………………………………………………………………………
ADDRESS………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………..
TEL. NO…………………………………FAX……………………………..EMAIL……………………………..
NAME IN WHICH THE POLICY IS TO BE ISSUED……………………………………………………………..
……………………………………………………………………………………………………………………..
TERM OF INSURANCE: FROM…………………….……..20……….. . TO…….………………...20…………..
PROPERTY TO BE INSURED
DESCRIPTION BUILDING 1 BUILDING 2
Full address (es) of premises
2. Construction of (a) external walls (a) (a)
(b) roof (b) (b)
Number of storeys
Method of (a) Lighting (a) (a)
5. OCCUPATION OF PREMISES:-
(a) Is the whole building used for Residential (a) (a)
purposes only?
If not please answer (b) to (g)
(b) Is any retail trade carried on? (b) (b)
(c) What manufacturing processes or repair (c) (c)
work (if any) are carried on within the
premises?
(d) How long have you been in this business? (d) (d)

DESCRIPTION BUILDING 1 BUILDING 2
(e) Is any trade or business other than that of the (e) (e)
proposer carried on within the premises?
If so, give particulars.
(f) What are the contents of the premises? (f) (f)
Are any of the goods to be insured of a hazardous (g) (g)
nature?
(h) Are there any hazardous goods located outside (h) (h)
the building (s) and within 30 feet thereof?
If so give particulars.
(I) Any portable Fire Extinguisher (I) (I)
6. ADJOINING OR ADJACENT BUILDINGS (IF ANY):-
(a) What is the Construction of (a) (a)
(I) External Walls? (I ) (I )
(ii) Roofs? (ii ) (Ii )
(b) How are the buildings occupied? (b) (b)
(c) What is the distance between adjacent (c) (c)
building and the premises to be insured?
(d) Are adjoining buildings cut off by brick, stone (d) (d)
or concrete walls, at least 9 inches thick,
without openings, going up to and through
the roof? If not, give details of the separation.
Are there any circumstances apart from those dealt
with above which appear to increase the risk of
loss or damage by any of the perils to be insured
against? If so, give particulars.
8. AMOUNT TO BE INSURED WHICH SHOULD
BE THE FULL MARKET VALUE:-
(a) On the building (a) (a)
N.B. Boundary and Compound walls, gates and
fences are excluded from the Insurance.
(b) On household furniture, furnishings and personal (b) (b)
effects therein (delete if not to be included).
(c ) On office furniture and equipment, trade fixtures (c ) (c)
and fittings therein.
(d) On machinery and plant therein. (d) (d)
(e) On stock and materials in trade therein. (e) (e)
(f) On……………………………...months’ rent. (f) (f)
(g) On…………………………………………………….. (g) (g)

IMPORTANT: The sum insured under each item will be separately subject to AVERAGE.
This means that if the actual value of the property is greater than the sum
insured you will bear a rateable proportion of the loss accordingly.
9. If there is any fire insurance in force on the same property, state:-
(a) Name of Insurer (s)
(b) Amount of Insurance (s)
10. Have you ever had a Proposal or Renewal of Insurance declined, or a Policy cancelled, or Renewal invited at an increased rate? If so, state name of Insurer and full particulars in each case.
11. Have you ever suffered loss by any of the perils to be insured against? If so give particulars.
12. Do you - (a) Take stock at least once a year? (a)
(b) Keep a proper set of account books? (b)
(c) Keep such books in a fire-proof safe? (c)
(d) Remove such books to another building (d)
when the above premises are closed?
13. Do you require insurance against:-
(a) Explosion (e) Tornado
(b) Earthquake and Volcano (f ) Riot, Strike & Malicious Damage
(c) Aircraft and Vehicle Impact (g) Water Damage
(d) Flood
14. Additional questions if additional perils insured against -
(a) Do the premises abut the road.
(b) How far are the premises from the nearest River or Sea.
(c ) Are the premises built on a Hillside.
15. Please check the proposal carefully before signing the Declaration Below -
DECLARATION
I/We desire to effect an insurance in the terms of the usual Policy for Fire insurance and declare that the above statements and particulars are true. I/We further declare that this Proposal shall be the basis of the Contract between me/us and the Insurer and that the amounts to be insured represent to the best of my/our knowledge and belief the full market value of the property stated.
Date……………………………………………………….. Signature……………………………………………………….

A COPY OF THE POLICY IS AVAILABLE UPON REQUEST.

A sketch of the premises and adjoining or adjacent buildings (if any) should, if possible,
be given here. In particular the sketch should show all doorways windows, or any other
openings both in external and internal walls.
NOTE: THE COMPANY RESERVES THE RIGHT TO DECLINE ANY PROPOSAL.