H eritage Insurance Company of Zimbabwe (Private) Limited

BARD HOUSE, 69 SAMORA MACHEL AVENUE, P O BOX 2469, HARARE Tele : 705221-7 727294-9
Fax : 705228/727299
E-Mail:insure@heritage.co.zw

BUSINESS COMBINED PROPOSAL FORM

(Where questions require a “Yes” or a “No” answer, tick that which is appropriate)

NO COVER IS IN FORCE UNTIL THE COMPANY HAS ACCEPTED THE PROPOSAL

Full Name

Postal
Address

Situation of Premises Stand No. Street

Suburb Town

Construction of Premises Walls Roof

Floors No. of Storeys

Occupied : (a) by the Proposer as :

(b) by others as :

Are premises occupied after business hours by the Proposer or his Manager? Yes No

If not, state whether a Watchman or Caretaker is employed and what special precautions are adopted for
protecting the premises :

How long have you carried on the present business ?

Do you keep a complete set of books and are such books locked in a fireproof safe or removed from the
premises after business hours? Yes No

When does your Financial Year end?

State name and address of your Auditors :

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Is there any other insurance effected upon this property? Yes No

Have you at any time in respect of any of the risks to which this Proposal refers (whether at the above premises
or elsewhere) :

(a) been insured or proposed insurance? Yes No

If so, state name of Insurer :

(b) Suffered any loss or damage or incurred

any liability? Yes No

If so, give particulars :

Have you or any firm of which you were a Partner or Director ever been bankrupt, insolvent, made an assignment
or compromised with Creditors? Yes No

Has any Insurer at any time in respect either of yourself or of a firm of which you were a Partner or Director :

(a) declined any Proposal submitted? Yes No

(b) cancelled or not invited renewal of any Policy? Yes No

(c) required an increased premium or imposed special

conditions in respect of any insurance? Yes No

SECTION 1 - FIRE AND ALLIED PERILS

SUM INSURED

The building, including Landlord’s Fixtures and Fittings. $

Architects and Surveyors Fees in respect of the said Building. $

Months Rent Payable / Receivable / Rental Value. $

Stock and Materials in Trade, including Goods held in Trust or on Commission. $

Machinery, Plant, Tools, Fixtures and Fittings. $

Other (including fire brigade charges, cost of debris removal) $

SECTION 2 - BUSINESS INTERRUPTION

1. GROSS PROFIT

Being the amount by which :

(i) the sum of the Turnover and the amounts of the closing stock and work in progress shall
exceed.

(ii) the sum of the amounts of the opening stock and work in progress and the amount of the
uninsured working expenses.

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UNINSURED WORKING EXPENSES

1. Purchases less discounts received

2. Discounts allowed

3. Bad debts written off

4. Carriage

5. Packaging

6. Consumable stores

NOTE : The amounts of the opening and closing stocks and work in progress shall be arrived at in
accordance with the Insured’s normal accountancy methods due provision being made for
depreciation.

2. Additional Increase in cost of working $

3. Fines and Penalties $

4. Claims Preparation Costs $

Indemnity Period Months

SECTION 3 - ACCOUNTS RECEIVABLE

Being LOSS OF OUTSTANDING BOOK DEBTS through loss or damage to accounts records.

Please state maximum amount likely to be outstanding at any one time $

Amount to be insured on AUDITORS CHARGES incurred in connection with any claim $

N.B : The amount of debts outstanding at the end of each month must be declared to the Company within
30 days, as this figure will form the basis of any claim which may arise.

SECTION 4 - BURGLARY

Sum Insured $

First Loss Basis Yes No

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 SECTION 5 - MONEY

Limit of Indemnity - Money in safe or in transit. $

DEFINITION OF MONEY : Cash, Bank and Currency Notes, Uncrossed Cheques, Postal Orders or Money
Orders, Postage Stamps and Revenue Stamps, the property of the Proposer.

GEOGRAPHICAL AREA COVERED : Zimbabwe.

PARTICULARS OF SAFE(S) AND / OR STRONGROOM:

Situation

Make

Date of Manufacture

Dimensions

Weight of Safe

How is Safe fixed

Number of keys to each Safe / Strong room

By whom are keys held

Are all keys removed from premises after business hours

SECTION 6 - GLASS

Value of fixed plate glass to be insured :

(a) External $

(b) Internal (Counters, Mirrors, etc) $

Value of lettering on windows and / or doors $

SECTION 7 - GOODS IN TRANSIT

Maximum value of any one Transit $

Estimated total value of all Transits during 1 year $

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 SECTION 8 - ALL RISKS

Articles Insured

1. $

2. $

3. $

4. Miscellaneous Articles (subject to Average) $

SECTION 9 - PUBLIC LIABILITY

Apart from deliveries do you undertake any work away from the premises? Yes No

Do you wish to include legal liability for :

injury, disease, loss or damage caused by goods or commodities sold,

supplied, serviced, tested or processed by you?

If so, please state Annual Turnover $

And Annual Wage Roll $

State make and carrying capacity of any lifts, hoists and other lifting machinery.

State Limit of Indemnity required in respect of any one accident. $

SECTION 10 - EMPLOYERS LIABILITY

Indemnity against legal liability at Law to Employees for death or bodily injury caused by an accident arising out of
and in the course of their employment.

Estimated Earnings of:

(1) Administrative and Clerical Employees $

(2) Others $

NOTE : The Cover provided is limited to $20 000 000,00 any one claim any one year of insurance.

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SECTION 11 - PERSONAL ACCIDENT

1. EARNINGS BASIS

i) NAMED EMPLOYEES

NAME OCCUPATION Estimated Annual

Earnings

ii) UNNAMED EMPLOYEES

OCCUPATION Estimated Number Estimated Annual

Earnings

COMPENSATION - EARNINGS BASIS

A. Death occurring within twelve calendar months from the A. A capital sum equal to times
happening of the accident. the Average Weekly Earnings.
B. Permanent Disablement resulting within twelve calendar B. Percentage of Compensation A as detailed
months from the happening of the accident. in the Table of Compensation.
C. Total and absolute incapacity from following usual C. A sum equal to 75 percent of the Average
employment for a longer period than one week. Weekly Earnings for each week of such
incapacity.
D. Medical, Surgical or Hospital treatment incurred as the D. Not exceeding $
result of the injury within twelve calendar months from
the happening of the accident.

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2. FIXED COMPENSATION BASIS

NAME OCCUPATION CAPITAL SUM

COMPENSATION - FIXED BASIS

A. Death occurring within twelve calendar months from the A. The Capital Sum.
happening of the accident.
B. Permanent Disablement resulting within twelve calendar B. Percentage of Compensation A as detailed
months from the happening of the accident. in the Table of Compensation.
C. Total and absolute incapacity from following usual C. $ per week.
employment for a longer period than one week.
D. Medical, Surgical or Hospital treatment incurred as the D. Not exceeding $
result of the injury within twelve calendar months from
the happening of the accident.

Has any Employee / Insured Person :

i) ever been declined or had special terms imposed for Life or Accident Insurance, or has any Company
ever cancelled or refused to renew his / her Policy?

If so, give particulars with dates

ii) ever suffered from any affection of the Heart, Lungs, Brain, Urinary or Genital Organs, or has any
physical defect or infirmity of any kind?

If so, give particulars with dates

Commencement Date of Insurance Renewal Date

DECLARATION :

I / WE DECLARE THAT :

1. The particulars entered in this Proposal Form are correct.

2. If the premiums for any Policy issued have been calculated on estimates furnished by
me/us, I/we agree to render at the end of each period of insurance a statement as required by the
Company and should such estimates be exceeded, to pay the additional premium due.

3. During the currency of the Policies I/we will maintain the property in good repair and all
reasonable precautions will be observed for the prevention or minimisation of any loss
or damage.

4. This Proposal and Declaration shall be the basis of the contract or contracts between
me/us and the Company and I/we will accept the Company’s Policies subject to the
terms and conditions contained therein.

Proposer’s signature Date

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