Statement of Values | Wilson Insurance

Co-Insurance Clause (to establish a rate):

Name:

Situate:

(a) The values in Column 2. ''Buildings including Fixtures and Fittings pertaining thereto''. are based on the cost of entirely rebuilding with new materials of similar kind and quality at to-day's prices, on:

the value of foundations below the level of the lowest floor.(b) Foundations: The values of "Buildings"

(c) The values in Column 3 -

"Machinery, Utensils, Furnishings & All Contents except Stock, Customers" Goods & Property owned by others including Employees' Effects & Tools'', are based on the cost of replacing all the property with similar kind & quantity at today's prices on:

(d) The values appraisal for property mentioned in Columns 2 and 3 (Buildings, Machinery, etc.) was made

date:

by:

(e) The values in Column 4 "Stock", are based on:

(State whether cost price or otherwise)

(f) (i) The values in Column 5 "Customers" goods and Stock belonging to Others'', are based on:

(State how value is arrived at)

(ii) State whether values include

(a) all such property:

(b) only such property for which the Insured is legally responsible:

(iii) State whether liability has been specifically assumed by contract or agreement:

(g) (i) The values in Column 6. "Property owned by others, including Employees" effects and tools (excluding values given in Column 5'') are based on:

(State how value is arrived at)

(ii) State whether values include

(a) all such property :

(b) only such property for which the Insured is legally responsible:

(iii) State whether liability has been specifically assumed by contract or agreement:

(h) The following property on the premises is not included in the values and is to be excluded from the insurance:

I/We hereby certify that the values given herein represent to. the best of my/our knowledge and belief, the actual values of the property described. if to be insured on ACTUAL CASH VALUE BASIS; or cost of replacement of the property described, if to be insured on a REPLACEMENT COST basis.

(i) Do you intend to make capital expenditures during next 12 months?:

IF THE ANSWER IS 'YES'. give an estimate of values and location of such expenditures.

Building

Value: $

Location:

Approximate Commencement Date:

Approximate Completion Date:

Estimated Increase in Stock Values:

Equipment

Value: $

Location:

Approximate Commencement Date:

Approximate Completion Date:

Estimated Increase in Stock Values:

The attention of the signatory is drawn to Statutory Condition #1 of the Fire Policy which reads as follows: Misrepresentation 1. If any person applying for insurance falsely describes the property to the prejudice of the insurer, or misrepresents or fraudulently omits to communicate any circumstance which is material to be made known to the insurer in order to enable it to judge of the risk to be undertaken, the contract shall be void as to any property in relation to which the misrepresentation or omission is material.

Date:

Completed By:

Official Position:

(NOTE: This form must be signed by a Senior Officer of The Corporation, whose official title must be given).

Statement of Values

Date of Policy or Renewal:

NOTE 1- The policy wording will be drawn to cover only property for which values are given in the respective columns.
NOTE 2- Separate values are required on each separately rated building (and on its contents if included in the insurance).

Column 1

Location 1

Occupancy:

Location 2

Occupancy:

Location 3

Occupancy:

Location 4

Occupancy:

Location 5

Occupancy:

Location 6

Occupancy:

Location 7

Occupancy:

Location 8

Occupancy:

Location 9

Occupancy:

Location 10

Occupancy:

Column 2 -- (a) & (b) above -- Building

Location 1