<p> Preliminary insurance questionnaire│ Private client by Hiscox</p><p>This document forms part of your insurance contract and must therefore be completed and signed prior to inception.</p><p>BROKER</p><p>Broker: Mr / Mrs: Phone number: Fax: Email: Effective date: / / Current insurer : Current premium amount: €</p><p>PROPOSER</p><p>Surname, first names of the insured: If company (SCI, SARL etc.), please specify its corporate name: Name of the legal representative of the company (if different): Profession: Marital status: Birth date: / / Address of correspondence: Address of the building to be insured (if differs from the above address):</p><p>PREMISES You are: owner | co-owner | tenant │ usufructuary│ bare owner undivided owner</p><p>You are: occupier | non-occupier Residence: main - permanent | secondary</p><p>FLAT – Surface area: m² | habitable outbuildings1 (maid’s room, studios...): m² cellar: m² │ terraces: m² │ other unhabitable outbuildings (greenhouse, garage...): m² Situation: floor of │ under terraces │ under maid’s room </p><p>OR HOUSE – The residence is: a house │ a mansion │ a castle │ a chalet │ others: </p><p>Buildings are built in: stone │ wood │ breeze block │ thatched roof</p><p>Developed area: (Main building, including adjoining outbuildings, cellars and attic): m² habitable outbuildings1 (caretaker’s, guests’): m² unhabitable outbuildings (pool house, garage...): m² │Surface area: ha If other address, please specify: </p><p>General global state: excellent │ good │ medium │ repairs required | Year of construction: </p><p>Fixtures and fittings (wooden floor, ceilings, windows, doors, fixed elements of kitchens-bathrooms) │ Amount: € Works on-going or planned: yes no │ Duration / type : </p><p>The property is listed MH or inscribed ISMH: yes no │If yes, please specify: </p><p>The property is located in an aggravated risk area : (liable to flooding area ; overhanging a cliff, natural risk prevention plan on-going or studied etc.): yes no</p><p>If yes, please specify: The residence is rented out (in part, totally, annually, temporarily): yes no </p><p>If yes, please confirm : The rental’s frequency: € │ Duration: │Amount of the rent: € Business purposes: yes no │ If so, please give details: </p><p>Farming yes no</p><p>Open to the public: yes no │ Guest houses: yes no │ Number of guest rooms: </p><p>...... Autres (séminaires, feux d’artifices...) : </p><p>PROTECTION - PREVENTION</p><p>The residence is: </p><p>1 Or unhabitable</p><p>1/3 permanently caretaking (24h/24 and everyday): yes no</p><p> partially │ Hours: │ Frequency: </p><p> no caretaker</p><p>Theft detection system: yes no │ Year of the installation: related to: central station 24/7 | third party │ personal phone number with: annual maintenance contract │ GSM transfer or other ADSL or line surveillance</p><p>The lowest access door are: armored │ full │ provided with multi-point locks │ provided with anti-angle clamps</p><p>The accessible openings (less than 2.50 m above the floor) are equipped with shutters, blinds, bars or burglary glazing: </p><p> yes no | If no, please specify: </p><p>Safe-deposit box: yes no │ Number: │Class: │ sealed │ protected by contactor/volumetric detectors</p><p>Fire detection system: yes no │ related to telemonitoring │ with: annual maintenance contract</p><p>Lightning conductor (paratonnerre): yes no │ Lightning arrester (parafoudre): yes no | Electric surge protector</p><p>(parasurtenseur): yes no</p><p>Other security means: </p><p>CONTENT, FINE ART, VALUABLES…………… ………… TOTAL AMOUNT (B)+(C)+(D): €</p><p>(B) GENERAL CONTENT (furniture and daily objects, electrical appliance, linens…): € Personal effects: € </p><p>(C) ART AND COLLECTION OBJECTS: total amount : € single item max. amount: € Including declared value</p><p>Paintings total amount: € single item max. amount: € Furniture total amount: € single item max. amount: € Fragile objects* total amount: € single item max. amount: € Others (wine, arms, etc.): total amount: € single item max. amount: €</p><p>* Porcelain biscuit, glassware, crystal, earthenware ... Including agreed value, according to expertise or inventory attached, directed by : </p><p> reference: date: / / amount: € maximum unit amount: €</p><p>2/3 (D) VALUABLES: total amount: € single item max. amount: € (jewellery, watches, precious stone or semi-precious, precious metal items, platinum, gold, silver-gilt, sterling silver, plate etc.). Including declared value</p><p>Whole world total amount: € single item max. amount: € In the insured dwelling total amount: € single item max. amount: € In bank safe total amount: € single item max. amount: € </p><p>Including agreed value, according to expertise or inventory attached, directed by: </p><p> reference: date : / / In the insured dwelling total amount: € single item max. amount: € In a safe in the insured dwelling total amount: € single item max. amount: € In bank safe total amount: € single item max. amount: € Worldwide total amount: € single item max. amount: €</p><p>The required sums insured fits with the total value of all existing items: yes no</p><p>If not, for which items: content │ art and collection objects │ precious objects </p><p>Other policy covering fine art: yes no │precious objects: yes no</p><p>Minimum standard excess per claim: 1 000€ or opt for a premium decrease choosing an excess per claim of: 2 000 € │ 3 500 € │ 7 500 € │ 10 000 € │ Superior amount : € </p><p>CLAIMS</p><p>Has there been losses or damages at the insured address in the last 5 years? yes no │ If so, please specify: </p><p>Date Nature (Theft, water damage, natural catastrophes, etc.) Cost Causes have been repaired € yes no </p><p>€ yes no </p><p>€ yes no </p><p>Has there been losses or damages at others addresses ?: yes no │If so, give date, nature damages and cost for each of them: Has any insurer cancelled any insurance for the proposer in the last 5 years ?: yes no </p><p>If so, please give details about the cancellation:</p><p>DECLARATION I undersigned declare that all the information provided in connection with this proposal, whether in my own hand or not, is true and that I have not withheld any material facts. I understand that non-disclosure or misrepresentation of material fact will entitle underwriters to cancel this insurance since its inception (Article L 113-8 du Code des Assurances) or to reduce the indemnity (Article L 113-9 du Code des Assurances). I understand that the signing of this proposal does not bind me to complete the insurance but agree that, should a contract of insurance be concluded, this proposal and the statements made in it and the information provided in connection with it will be relied upon by the underwriters in deciding whether to accept this insurance and will form part of my insurance contract. Your signature is required to the project’s validation. </p><p>Done in Date / / Signature of proposer</p><p>3/3</p>