Residential Insurance Quote Request

Personal Information
Full Name:
Full Name required.
Occupation:
Mailing Address:
Email:
Email Address required.
Please enter a valid email address.
Telephone: Home:   Cell:   Work:
Fax:
Address of Property to be Insured:
Are you:


Please Select One.

Period of Insurance: From: Start Date required. Please use format dd/mm/yyyy.   To: End Date required. Please use format dd/mm/yyyy.

 

  Please Answer the following questions: YES NO
1. Is your Home or outbuildings:
  (a) built other than of brick, stone or concrete and roofed other than with slates, tiles or concrete?
  (b) In an area subject to flooding or overflow of the sea?
  (c) Protected by sea walls?
  (d) Used for any business purposes?
  (e) Occupied by tenants or paying guests?
  (f) Regularly left unattended as a result of all adult residents being in full or part time work?
  (g) Left unoccupied for any other reason?
  If you answered YES to any of the above questions please give details below:    
     
 

 

 YES NO
2. Is the dwelling a condiminium?
  Are you responsible for the fixtures & fittings (tub, toilet, hot water heater, kitchen, cabinets, etc)?
3. Is the dwelling an apartment?
  Is there a separate locked entrance under your sole control?
4. Does the dwelling have any security of fire suppression features?
5. Have you or any members of your family permanently residing with you:
  a. suffered any loss during the past five years from any of the events against which you wish to insure?
  b. been refused insurance by any insurer for any of the events against which you wish to insure?
  If you answered YES to any of the above questions please give details below:    
     

 

Description of Property Insured
    SUM INSURED
1. The buildings of your home:      
 
Basis of Sum Insured. Your Sum Insured should represent the cost of rebuilding your Home including garden walls, domestic outbuildings and swimming pools. An allowance should also be made for architects' and surveyors' fees and the cost of removal of debris following a loss.   Buildings: $
Sea Walls: $
Docks: $
Name of morgagee:  
 
2. The contents of your home:      
 
Basis of Sum Insured. The full replacement value as new of all Contents less an allowance for wear and tear on clothing and household linen. Satellite Dish: $
Contents: $
Does the Sum Insured represent the full value of the Contents calculated on the same basis as that described above? YES NO  
 
If NO please give details below:  
Does the value of articles of precious metal, furs, paintings, works of art, collections of coins, medals or stamps exceed $5,000? YES NO  
 
If YES they should be specified below (Evidence of value is required for Specified Contents):
 
3. Your personal possessions (all risk cover) Do You Require Cover? SUM INSURED
Basis of Sum Insured (Indemnity)
  YES NO  
(a) Unspecified Articles, Personal Effects and Clothing where the value does not exceed $1,000 per item. $
The minimum insured for this section is $2,000.
This section also provides cover for the loss of money and credit cards.		      
 
(b) Specified Articles (Agreed Value) whose value exceeds $1,000 per item. Please list in the boxes below a full description of each item and its value. Evidence of value is required for these items.  
PROPERTY DESCRIPTION SUM INSURED
$
$
$
$
$
 
  YES NO  
(c) Sports Equipment.  
Please state which type of equipment is to be insured:  
Fishing $    Golf $    Tennis $    Cricket $    Other $   
 
(d) Petal Cycles. $
(e) Freezer Contents. $
What is the Year and Make of the Freezer:

 

Public Liability Cover - Owner/Occupier
The Indemnity Limit offered by Colonial Insurance Company Limited amounts to $1,000,000 and the cover offered is only available with the covers under Section 1 and/or 2 in that it protects you for your liability to others as the owner and/or occupier of the of the Insured Home.
Family Personal Liability.
Cover is available for the sums which you or any member of your family may become legally liable to pay for accidents occuring in Bermuda not connected with the ownership or occupation of your Home.
  YES NO
Please indicate if you require this cover.

 
Workmens Compensation for Domestic Employees.
Please indicate if you require cover.
Number of Employees:   Indoor:   Outdoor:

Travelsure - An Annual Travel Cover
Please print full names of persons to be insured and state the number of days each person expects to be away from Bermuda.
Name Date of Birth 30 Days 60 Days 90 Days 120 Days

 

Declaration: (Complete in all cases)

Please read the following declaration very carefully and read again the questions and answers, especially if not completed in your own hand, before signing the form.

I/We declare to the best of my/our knowledge and belief that:
(a) the answers given are true.
(b) All material particulars affecting the assessment of risk have been disclosed.

I/We agree that this Proposal and Declaration shall be the basis of the contract between me/us and the Insurers and shall be deemed to be incorporated in such contract, subject to the terms and conditions of the policy issued by the Insurers. If any answer has been written by any other person, such person shall for that purpose be deemed to be my/our agent and the agent of the insurers.

 I agree to the declaration above.
You must agree to the declaration before submitting the form.

All quotes are subject to medical underwriting. Quotes do not guarantee insurance.