Home Insurance

Date:

DayMonthYearHourMinutesAM/PM Option
Guardian Group Incorporated Agent: Alafia Whiskey

(C) 378-4666 (O) 294-7587(PLUS)

(E): alafia.whiskey@myguardiangroup.com

(E): admin@iwantprosperityplus.com

(W): www.iwantprosperityplus.com

Address: Sean David Branch, Guardian Life,
9-13 Endeavour 1st Street, Endeavour Industrial Estate, Chaguanas
Home Insurance Form
First Name*
Last Name*
Birth Date

DayMonthYear
Risk Location/ Home address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Value/ Sum Insured
Condition of building
Cell*
Format: (000) 000-0000.
Home
Format: (000) 000-0000.
Occupation
Employer
Work
Format: (000) 000-0000.
E-mail
External wall

ConcreteConcrete and clay blocksWoodOther
Internal wall

ConcreteConcrete and clay blocksWoodOther
Roof type

Metal/ galvanizeConcreteShinglesClay tiles
Roof design

High pitchedHippedGableFlatOther
Roof anchor

Metal or bolt anchoredNailed to the wallConcrete slabOther
Floor

ConcreteWoodOther
No. of Storey(ies)
In what year was the building constructed
Has the building been renovated since

YesNo
If Yes, specify. Was any electrical work done
Is the building

Detached single-family unitDuplex (2 family)Block/ row of flats/ townhouseSelf contained flat with exclusive entrance
Situated on

Flat landLevelled or reclaimed landSloped/ hillsideOther
Are there retaining walls on the property?

YesNo
Value of Retaining Wall
Is the building

TenantedOwner occupiedTenanted & Owner occupiedUnoccupied
Marital Status

SingleMarriedDivorcedSeparatedWidowed
Is the whole building being used for residential purposes

YesNoOther
Mortgagee
Claims/ losses
What type of security is there against loss by burgulary or theft
What type of protection is there against loss by fire
Comments
Effective date of insurance

DayMonthYear
Should be Empty:

Home Insurance Form