P A L L A D I U M H o m e I n s u r a n c e P r o p o s a l F o r m

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1 P A L L A D I U M H o m e I n s u r a n c e P r o p o s a l F o r m P R O V I D I N G P E A C E O F M I N D

2 The Proposer You must take reasonable care to provide complete and accurate answers to all questions. If any of the shaded YES or NO boxes are ticked, please ensure that appropriate additional information is detailed in the space provided on page 5. Failure to do so may result in a delay in issuing the policy document. ALL QUESTIONS MUST BE ANSWERED Full name(s) Postal address Postcode Address of property to be insured (if different) Postcode Occupation(s) (including type of business, part-time and any voluntary work) date(s) of birth telephone number(s) (home) (work) (mobile) date cover is to commence Buildings Contents details of any other interests to be noted such as bank, building society or other lending institution including address and reference the policy includes a standard excess of 250 increasing to 1000 for subsidence. do you wish to increase the standard excess in return for a reduced premium? ,000 Other Have you, or any member of your household: (i) suffered any loss or damage (other than for motor) whether insured or not in the last 5 years? (ii) ever had insurance refused, cancelled or subjected to special terms? (iii) any County Court Judgments, criminal convictions, charges (other than motoring offences), individual Voluntary Arrangements (iva), the bankruptcy, insolvency or disqualification from acting as a company director of you or any person insured by this policy Yes no 1

3 Risk Information If any of the shaded YES or NO boxes are ticked, please ensure that appropriate additional information is detailed in the space provided on page 5. Failure to do so may result in a delay in issuing the policy document. ALL QUESTIONS MUST BE ANSWERED 1. The Property the buildings (including outbuildings) at the address of the property to be insured: (a) when were they constructed (b) are any of the buildings listed? if YeS, give details and advise status (c) are they built of brick, stone or concrete? (d) are they roofed with slates, tiles, concrete or metal? (e) is there a flat roof that exceeds more than 20% of the total roof area? if YeS what is the construction ie felt, rubber, concrete (f) are they to your knowledge located in an area free from flooding (g) are they to your knowledge located in an area free from coastal or river erosion? (h) located within 200 metres of any streams, rivers, lakes or sea? (i) to your knowledge have the buildings or grounds ever flooded? (j) are they free from any signs of external cracking? (k) to your knowledge have they ever suffered from subsidence, landslip or heave? (l) to your knowledge has the property ever been monitored for subsidence, landslip or heave? (m)are there any shrubs or trees more than 10 metres tall within 10 metres of any of your buildings whether inside your property or not? (n) are they in a good state of repair? (o) are they regularly maintained? (p) likely to have any structural work carried out within the next 12 months (other than regular maintenance)? (q) a house a flat if a flat, please state floor (r) occupied by you as your primary home? (s) occupied by you as a weekend or holiday home? (t) occupied, in whole or in part, by tenants, or by others as a holiday home? (u) regularly left unattended (other than during normal working hours)? (v) used for any business purposes? (w)please state type of heating (eg oil/gas etc) 2. Security (a) Are all exit doors fitted with 5 lever mortice deadlocks or multi-point locking systems? (b) Are all accessible windows, fanlights or skylights fitted with key operated locks? (c) Are french/patio doors fitted with key operated locking bolts top and bottom or multi point locking systems? (d) is the property fitted with a professionally installed burglar alarm system? if YeS,if yes is there a maintenance contract in force? State type of signal Bells only Central station redcare Other (e) does the property have a floor or wall safe or strong room or vault? if YeS, give details including make, model and cash rating (f) Are there any other security arrangements (e.g. CCtV, security lighting)? if YeS, give details Yes no 2

4 Definitions Buildings Your home including interior decorations, fixtures and fittings including fitted furniture and fitted appliances; swimming pools, ornamental fountains and ponds; hard tennis courts, terraces, patios, driveways and footpaths, greenhouses; walls, gates, fences and hedges; underground service pipes, cables, sewers and drains; underground and fixed domestic fuel tanks; externally fixed radio and television aerials, satellite dishes, their fittings and masts all belonging to you or for which you are legally responsible. Extended Replacement (not available for grade 1 and grade A listed buildings) we will where you have provided us with a full independent professional valuation which we have accepted and which is no more than 5 years old, pay up to 125% of the index linked sum insured for restoring, repairing or rebuilding damage to the insured buildings provided that such work is carried out and only if you 1. have notified us of any additions, alteration and improvements to the buildings 2. have amended the sums insured to adequately reflect such work 3. pay any reasonable resultant additional premium we require. Tenants Improvements improvements, alterations, decorations which have been undertaken, as tenants, by you or previous occupiers and which are not covered by the landlord s or other insurance. Contents Household goods; carpeting, furnishings, and equipment; food and drink including the contents of refrigerators and freezers; personal effects; fine art and antiques; business contents; domestic heating oil; garden equipment and furniture; outdoor items; golf trolleys, golf buggies, motorised and non-motorised invalid transport; quad bikes used only for gardening, horse and pet maintenance or incidental farming activities; pedestrian controlled power driven toys and models; electrically powered sit-in toy and model vehicles all belonging to you or for which you are legally responsible. Personal Effects Clothing, baggage and items worn, used or carried by you including spectacles, contact and corneal lenses, hearing aids; photographic equipment; mobile communication and computer equipment; sports equipment including guns, pedal cycles, saddles and tack and any specialist sports clothing; hand propelled watercraft; other similar items. Outdoor Items items designed to be left outdoors including garden furniture, children s play equipment; statues and ornaments. Business Contents Office furniture and equipment, stationery, software, books, deeds, documents and reference materials all belonging to the business or for which the business is legally responsible. Fine Art & Antiques items of artistic merit or historical value including antique and designer-made furniture; paintings, drawings, etchings, prints and photographs; tapestries, carpets and rugs; sculptures, porcelain, glass and objets d art; clocks, barometers and mechanical art; books and manuscripts; stamp and coin collections; articles made of precious metals or precious stones including gold, silver and plated items; collections, collectibles and sets of similar items. Valuables Jewellery, watches and furs belonging to you or for which you are legally responsible. 3

5 Sums to be Insured when completing this section you are recommended to refer to the policy definitions on page 3. a. Buildings (full rebuilding costs including professional fees, clearance and additional costs) main residence Outbuildings tenants improvements Total do you require extended replacement cover? Yes (not available for Grade 1 or Grade A listed buildings) b. Contents (replacement as new cost) (EXCLUDING Fine Art & Antiques and Valuables detailed in c. and d. below) Total the following property falls within the definition of contents and any such items should be included in the total contents sum insured. Such property is subject to an inner policy limit and where the value is greater than the inner limit please state the increased sum insured required. Property Limit Sum Insured gold, silver and plated items 10,000 Business contents 15,000 guns 10,000 c. Fine Art & Antiques (current market value) the single article limit under this section is 25,000. Any individual item, pair or set in excess of this value should be specified on page 5 of the proposal form. Antique furniture Paintings and drawings tapestries, carpets and rugs Books, manuscripts and other documents Brittle objects, glass, porcelain, sculptures and pottery Statues and sculptures of a non-fragile nature Clocks, barometers and other mechanical art Stamp and coin collections Articles made of precious metals or stones, including gold, silver and plated items Other items of a collectable nature Any items kept OnLY in a bank or safe deposit* Any items kept permanently in a safe within the home Total d. Valuables (There is no cover either in or outside of the home unless a sum insured is provided) the single article limit under this section is 10,000. Any individual item, pair or set in excess of this value should be specified on page 5 of the proposal form. For antique and investment jewellery and watches, the current market value should be shown. For all other other items, the replacement value should be shown. Antique and investment jewellery and watches Other jewellery and watches Furs Any items kept OnLY in a bank or safe deposit* Any items kept permanently in a safe within the home Total *Name, address and postcode to be provided under Additional Information on page 5. 4

6 Specified Items Please detail any items over 25,000 to be specified under the Fine Art & Antiques section or items over 10,000 in respect of the Valuables section. we will also require sight of supporting valuations or purchase receipts (not more than 5 years old) if cover is confirmed. Additional Information 5

7 Important Notice Important Notice this policy is a legal contract which relies on the information provided by you. we use this information when we decide what cover to provide and how much you will pay. it is therefore essential that all the information given to us is complete and accurate and that you have not withheld or misrepresented any information which will affect your insurance. it is also important that, throughout the life of this policy, you tell us immediately if there are any relevant changes in your circumstances or to any information already given. if you are not sure whether something is important or relevant, please tell us anyway as failure to do so may affect a claim, the cover provided, invalidate your insurance or result in it not operating fully. if you would like to read the policy in advance of buying this insurance, please ask us to send a specimen wording or alternatively download a copy from our website Notifying us of a change You must notify us or your broker within 14 days of any changes to your circumstances or in the information given to us which may affect this policy whether at inception, during the life of the policy and/or at renewal. when we are notified of a change, we will tell you whether this affects your policy. For example whether we are able to accept the change and if so, whether the change will result in revised terms and/or a revised premium being applied to your policy. if we are not able to accept the change and it becomes necessary to cancel this insurance, we will do so as described in the cancellation conditions of the policy Should any of the information provided by you be incomplete or inaccurate, we reserve the right to a) cancel your policy and refuse to pay any claim or b) not pay any claim in full or c) revise the premium and/or change an excess or d) revise the extent of cover or the terms, conditions or exclusions of this policy. we strongly recommend that you keep a record of all information given to us, including telephone calls, copies of all letters, s and the proposal, questionnaires and claim forms you completed. A copy of this proposal form and completed questionnaires will be sent to you on request. APPLiCABLe LAw: the parties are free to choose the law applicable to this insurance. Unless specifically agreed to the contrary, this insurance will be governed by the laws of england and subject to the exclusive jurisdiction of the laws of england and wales. DECLARATION i/we declare that the information given in this proposal form and any questionnaires is, to the best of my/our knowledge and belief, true and complete and that i/we understand the implications of the paragraph headed notifying us of a change. where the answers to all or any of the questions have been completed by someone else, i/we confirm that i/we have read and agree with all the information given. i/we understand that you, Palladium Underwriting Limited, will pass the information on this proposal to insurance database Service Ltd (ids) and the Association of British insurers (ABi) so that they can make it available to other insurers. i/we also understand that, in response to any searches you may make in connection with this proposal or any claim i/we make, ids and ABi may pass any information received from other insurers to you. i/we understand that any quotation received may change when you receive and assess the completed proposal form and any questionnaires. You have the right to impose special terms or decline this proposal. i/we understand that the signing of the proposal form and declaration does not bind me/us to complete the insurance and that cover will not be in force until this proposal has been accepted by you and confirmation of cover is in my/our possession. i/we agree that the completed proposal and any additional information provided will be the basis of the contract between me/us and Palladium Underwriting Limited and that i/we will pay the premium when called upon to do so. Signature of proposer(s) date signed 6

8 PALLADIUM BrOKer StAmP P A L L A D I U M Underwriting Limited Palladium House, 10F Buntsford Park road, Aston Fields, Bromsgrove, worcestershire B60 3dX tel: Fax: Authorised and regulated by the Financial Conduct Authority. Financial Services Register number Companies House Register number PimS /15

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