HOME INSURANCE APPLICATION FORM - SAGITARIES INSURANCE SERVICES

PROPERTY DETAILS AND COVERAGE

Location to be insured

HOUSE/UNIT NO. BLOCK/LOT/PHASE NO.STREET/AVENUE/ROAD VILLAGE OR SUBDIVISION*

CITY*

PROVINCE*

ZIP

INTEREST TO THE PROPERTY BEING INSURED

IF OTHERS(PLEASE SPECIFY)

Property Information

AGE OF BUILDING

YEAR LAST RENOVATED*

HEIGHT*

IF MORE( PLEASE SPECIFY)

CONSTRUCTION

IF OTHERS(PLEASE SPECIFY)

ROOFING MATERIALS

IF OTHERS(PLEASE SPECIFY)

OCCUPANCY

IF OTHERS(PLEASE SPECIFY)

Boundaries(description of the surroundings of the property to be insured)

FRONT*

LEFT*

RIGHT*

BACK*

Coverage

BASIS OF SUM INSURED

Items to be Insured

BUILDING(PHP)

CONTENT(PHP)

LEASEHOLD & IMPROVEMENTS(PHP)

IS THE PROPERTY MORTGAGED?

YES
NO

IF YES(PLEASE INDICATE THE NAME OF THE BANK OR FINANCIAL INSTITUTION)

IS THERE ANY LOSS HISTORY FOR THE LAST 3 YEARS?

YES
NO

IF YES(PLEASE PROVIDE BRIEF DETAILS)

Period of Insurance

Inception

Expiry

Personal Details

TITLE

FULL  NAME*

MOBILE NUMBER*

EMAIL*

TIN

BIRTHDAY*

BIRTHDAY

ADDRESS*

CITY*

PROVINCE*

COUNTRY*

ZIP

BUSINESS/EMPLOYER'S INFORMATION

BUSINESS/EMPLOYER'S COMPLETE NAME

ADDRESS

CITY

PROVINCE

COUNTRY

ZIP