Household Insurance Form

Postal Addresses :

Location of Premises:

Type of Premises:

Do you own the premises:

Have you ever suffered a loss from any of the above perils?
If yes please provide details on a separate sheet.

Sum Insured (JD):-

Premium Calculation: Total sum insured JD x JD 3 = JD/1000
Please add 20%(Sales tax, stamps etc.)
Insurance will commence only after the issue of the policy.