QUESTIONS FOR HOUSEHOLD INSURANCE

INSURED DETAILS
Civil ID for Bulgarian citizens or date of birth for others:		Civil ID: Or  Date of Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912
Name: *
(As on the preliminary contract or notary deeds)
Your Correspondence Address:
House Number/Name:
Address: *
Town/City: *
County/Region:
Post Code:
Country: *
E-mail address: *
Telephone number: *

POLICY DETAILS
Policy start date:		As soon as possible Or Select Date Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912
Bank Beneficiary: (In case home is mortgaged in favor of a bank and the bank will be beneficiary for the policy, please enter bank details)		Name:

MAIN DETAILS OF HOME
Type: *		Select Type Apartment Villa
Occupancy:		Home is occupied permanently (primary residence)
Location (if different from the address of the Insured):
Please, fill out where applicable:
Name of Complex: *
Block No.:
Unit No.: *
Floor:
Apartment Area (sq.m):
Address:
Town/City: *
County/Region:
Post Code:

SUBJECT OF INSURANCE AND SUM INSURED
Currency (Please select a currency):		EUR   BGN
Subject of insurance:
(please indicate amount of coverage you need for all three categories; if you do not need coverage for any one category, please put 0 (zero); mark those for which the bank specified in section "Bank Beneficiary" will be beneficiary, if relevant)

Subject	Sum insured	Bank Beneficiary
Building
Contents
Liability	0  50,000 BGN/25,565 EUR  100,000 BGN/51,130 EUR  200,000 BGN/102,260 EUR

RISK RELATED DISCOUNTS
(To receive premium discount, please mark the statements relevant to the home)
Year Home Built: (Please select one from the listed, if relevant)		Select Any After 1987 Between 1956 and 1987 (inclusive)
Age of Water and Sewage Pipes and Electric Installation: (Please select one from the listed, if relevant)		Select Any Less than 11 years Between 11 and 20 years (inclusive)
Fire Protection: (please check the relevant)		Smoke detectors or fire alarm system is installed
Only for House, distance to water (river, lake, sea, dam): (please select one from the listed, if relevant)		Select Any Approximately more than 100m Approximately between 50m and 100m
Security: (please check the relevant)		Only for Apartment, the Home is on the 2nd floor or higher  Professionally installed monitored security system with respond up to 10 minutes  24 hours guards and video monitoring