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*
Home
Occupation
Employer
Work
E-mail
ConcreteConcrete and clay blocksWoodOther
ConcreteConcrete and clay blocksWoodOther
Metal/ galvanizeConcreteShinglesClay tiles
High pitchedHippedGableFlatOther
Metal or bolt anchoredNailed to the wallConcrete slabOther
ConcreteWoodOther
No. of Storey(ies)
In what year was the building constructed
YesNo
If Yes, specify. Was any electrical work done
Detached single-family unitDuplex (2 family)Block/ row of flats/ townhouseSelf contained flat with exclusive entrance
Flat landLevelled or reclaimed landSloped/ hillsideOther
YesNo
Value of Retaining Wall
TenantedOwner occupiedTenanted & Owner occupiedUnoccupied
SingleMarriedDivorcedSeparatedWidowed
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