APPLICATION FOR PHYSICAL PERSON CIVIL LIABILITY INSURANCE1

Insured person / Name, surname / Personal code
Declared address / LV-
Correspondence address
(Please name, if it is not the same as the domicile, declared address) / LV-
Phone / E-mail / Fax
Civil liability of the flat owner/ tenant / Address of the premises
State of the premises: property hired premises
Use of the premises:
For the living of the insured person and his/ her family members
Premises are hired to a third party
Name, surname and personal code of the tenant
Is it necessary to include a tenant in the insurance as an equally insured person (without the recovery)? / Yes
No
The premises are on the floor / Year the building was built on
Overall surface area of the premises (m²)
Wirings and water pipe system:
New Used, in good condition Used up/ in bad condition
Have there been any cases of water piping of heating accidents or other losses?
Yes No
When has the loss occurred? Who are the victims?
Amount of loss Cause of loss
Policy insurance period / From To
Limit of liability
The risk for own account / 140 EUR other EUR
Civil liability of the owner/ tenant of the building / Address of the building
State of the premises: property hired premises
Use of the premises:
For the living of the insured person and his/ her family members
The building has been rented to a third party
Name, surname and personal code of the tenant
Is it necessary to include a tenant in the insurance as an equally insured person (without the recovery)? / Yes
No
Year the building was built on
Overall surface area of the premises (m²)
Wirings and water pipe system:
New Used, in good condition Used up/ in bad condition
Have there been any cases of water piping of heating accidents or other losses? / No
Yes
When has the loss occurred? Who are the victims?
Amount of loss Cause of loss
Policy insurance period / From To
Limit of liability
The risk for own account / 140 EUR other EUR
Private person civil liability / The insured persons (family members)
Name, surname and personal code of the spouse
Name and surname of the children (name, surname, personal code)
Other relatives the insured persons have a common household with:
Address of the owned apartments / buildings
Address of the rented buildings / apartments
Wirings and water pipe system:
New Used, in good condition Used up/ in bad condition
Dog: Haven’t Have Number Sort
The necessary operation area of the policy:
Latvia Baltic countries EuropeWhole world
Have there been any cases of water piping of heating accidents or other losses? / No
Yes
When has the loss occurred? Who are the victims?
Amount of loss Cause of loss
Policy insurance period / From To
Limit of liability
The risk for own account / 140 EUR otherEUR
Contact person / Phone:
Comments
I affirm that I allow "Seesam", as a system administrator, a receiver of personal data and a personal data operator, to process my personal data. I also agree to receive newsletters from "Seesam".
This is to certify that I shall acquaint myself independently with the terms and conditions of the agreement in the insurer’s homepage or at the office.
In the event it’s impossible to acquaint with the terms and conditions of the agreement, please contact the insurer or the intermediary without delay.
Insured person / I / We, having signed below, affirm that according to my/ our belief and knowledge the statements made herein are true and correct and I / we agree that this application and any other additional information required by the insurance company and given herein, shall be considered as the base and shall be included in any insurance contract to be included between the applicant and the insurance company. I / We agree to inform the insurer about any significant changes of facts that may occur before the signing of the insurance contract.
Name, surname / Place, date
[day, month, year] / Signature

INFORMATION ABOUT THE INSURER

Insurer / Seesam Insurance AS Latvia branch
Domicile: Muitas street 1, Riga, LV-1010,
Phone: 67061000 Fax: 67061022 E-mail:
Representative of the insurer / Name, surname / Data / Signature

- The signing of this application does not oblige the company to offer an insurance nor the applicant to agree with it, but hereby an agreement is reached on considering this application to be the base for issue of any insurance contract. The applicant is responsible for the authenticity and completeness of the submitted data. If false data are submitted, the insurer has the right to refuse the payment of the insurance indemnity.