1. Please provide the following contact information:
First Name
Last Name
Street Address
Address (cont.)
City
Zip/Postal Code
Phone
FAX
E-mail

2. Insured Address:
Street No.
Soi
Street
Tumboon
Amphur
Province
Telephone/Fax

 

3. You occupy the resident as	Owner  Tenant
for residence only
4. Period of Insurance:
Commencing Date	-- mm/dd/yy
Expiry Date	-- mm/dd/yy
5. The resident is:	Isolated House Shophouse/Townhouse Apartment/Condominium

6. Details of Construction:	No. of Story
External Wall	Brick Wood Brick/Wood
Upper Floor	Concrete Wood
Roof Beam	Concrete Iron Wood
Roof	Concrete/Deck Tiles

7. Internal Area:	Width (m.)x
	Length (m.)
8. Insured Property is:	Building (Excluding Foundation) Furniture, Fixture, Fittings and Household Contents
9. Sum Insured:	Plan 1 B 300,000 Plan 2 B 500,000 Plan 3 B 800,000 Plan 4 B 1,000,000