Personal Combined Proposal Form PROPOSER: Address Street Address Address Line 2 City TELEPHONE EMAIL ADDRESS* TYPE OF PROPERTY (House, Flat, etc) RISK ADDRESS TYPE OF WALLING AROUND THESE PREMISES (i.e Fence, Du rawall etc) CONSTRUCTION OF RESIDENCE – WALLS ROOF SECURITY FEATURES (i.e Alarm, Electric Fence, Security Guard etc..state if reaction linked Period Of Insurance From To PREVIOUS LOSS HISTORY (last three years) Type of Loss Date of Loss Amount Insured (yes/no) Insurer’sName INSURANCE SUMMARY -- SUM INSURED Section 1 – Houseowners Buildings of the private residence at the risk address including garages outbuildings. Landlord’s fixtures and fittings walls gates hedges fences tennis court and swimming pool $ Name of Mortgagor Section 2 Household goods and personal effects of every description contained in the buildings at the risk address Section 3 – “All Risks” – anywhere in the world (see Specification overleaf) Section 5 – Personal Accident Insured Person(s) Insured Person(s) Date Of Birth Do any of the above have any physical Disability? YES/NO Yes No Benefits (a)Death $ (c) Temporary Total Disablement $ (d)Medical & Surgical Expenses $ DECLARATION: I apply for the insurance summarised above, it being understood that where no sum insured is shown against a Section no insurance exists under that Section. I declare that I have not had any insurance refused cancelled or withdrawn and that I have not withheld any material information. Date Proposer’s Signature Producer ALL RISKS SPECIFICATION Item Description (include serial numbers) On Personal Effects (as defined in the policy) Where Purchased When Purchased Sum Insured $ Date I hereby certify that the information in this application form is true and correct to the best of my knowledge and belief. I authorize Champions Insurance Company to furnish me with a quotation based on the information provided.