INSURANCE PROPOSAL FORM

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1 INSURANCE PROPOSAL FORM NOTE: Please fill in this form carefully. We will use the information you give on this form to decide whether we can insure you and to decide the premium and the conditions of insurance. If any of the statements made in this form are incorrect, any claim under any insurance certificate we issue may not be paid. A copy of the insurance certificate wording is available on request. In summary, insurance is available for:- Loss or damage to buildings and contents caused by:- Fire, lightning, explosion or earthquake. Theft or attempted theft. Storm, flood or weight of snow. Falling trees, telegraph poles or lamp posts, radio and TV aerials and satellite dishes. Escape of water and frost damage to fixed water tanks. Escape of oil from central heating installations. Smoke damage caused by faults in central heating installations. Subsidence, heave or landslip. Riots, violent disorder, civil commotion and malicious damage. Aircraft. Collision by any vehicle or animal. Accidental damage to fixed glass and double glazing, mirrors, oil and water pipes, sanitary ware, TV, audio, video and computer equipment. Costs of alternative accommodation or loss of rent after buildings damage. Temporary removal of contents to other private dwellings and buildings where you work. Fatal injury caused by fire or burglars. Loss of keys. Food in fridges and freezers. Accidental damage to buildings and contents. Accidental damage or loss anywhere in the world to valuables and personal possessions. Theft or accidental loss of money and/or credit cards. Legal liability as owner (if buildings are insured) or occupier (if contents are insured) and as a private individual and employer of domestic employees. Theft or accidental damage to pedal cycles. This is only a brief summary of the principal heads of insurance cover. For full details of the insurance, and the exclusions and limits of cover, you should refer to the full Insurance Certificate wording.

2 NOTE: Please fill in this form carefully. We will use the information you give on this form to decide whether we can insure you and to decide the premium and the conditions of insurance. If any of the statements made in this form are incorrect, any claim under any insurance certificate we issue may not be paid. Information about you Surname: First Names: Full Address (including Post Code): Postcode Telephone number: (home ) Mobile Telephone number: Date of Birth: _ Occupation: (work) Information about all members of your family who permanently live with you Name: (only include surname if different from above) Title Mr/Mrs/Miss/Ms Mr/Mrs/Miss/Ms Mr/Mrs/Miss/Ms (please delete as appropriate) Date of Birth: / / / / / / If more people need to be insured please continue on a separate sheet Information about the home to be insured Full address (including Post Code) : if different to address already given Postcode Type of property* (House/Bungalow/Purpose built flat/converted Flat/Or other (give full details) If the home is a flat, is it fully self-contained with its own lockable entrance under your sole control*? Year built? Number of bedrooms Please read and answer these questions carefully. Is the home built of brick or stone with a tiled or slate roof? Has the home ever suffered from flooding? Has the home ever suffered from subsidence, heave or landslip? Is the home being monitored for subsidence, heave or landslip? Is the home occupied only by you and the members of your family named above? Is any part of the home used for any business, trade or profession? Is the home regularly left unoccupied for more than 30 consecutive days? Yes/No

3 What security precautions do you have at the home? Please give full details of: Front door locks (eg 5 lever mortice deadlock) Locks to other external doors, including patio and french windows (eg deadlock, key operated bolts) Locks to garages, sheds and out-buildings Window locks (eg screw or key operated) Alarms - Who was the installer? Is there a maintenance contract with a member of NACOSS or Integrity 2000? Please send a copy of the specification with this form Safes - Type (eg wall, under floor, free-standing)? Make and Model? Any other security precautions? Information about the insurance you require (tick as appropriate) Buildings Do you require buildings insurance? What is the full cost of rebuilding the home? - please note this is not the market value (Please include garages, outbuildings, permanently installed swimming pools, tennis courts, drives, patios and terraces, walls, gages, fences, fixed central heating installations, fixed fuel and septic tanks, the cost of removing debris, making the buildings safe and all fees and associated costs)? Do you require accidental damage insurance for buildings? Contents Do you require contents insurance? What is the full cost of replacing the contents as new? - (Please include the cost of replacing valuables and personal possessions which are kept at the home)? Do you require accidental damage insurance for contents? Information about the insurance you require (continued) Do you require insurance for valuables and personal possessions when away from the home? Please list on the next page (a) all valuables and personal possessions worth more than,2,500 which you may take away from the home (b) the total value of all jewellery kept in the home What is the maximum value of all other valuables and personal possessions which you may have away from the home at any time? (This means the full cost of replacing such items as new) Do you require insurance for money and credit cards? What limit of insurance do you want for (a) money? (b) credit cards? Do you require insurance for pedal cycles? Please list all pedal cycles for which you require insurance and give the value of each cycle Do you require insurance for caravans? Please list all caravans for which you require insurance and give the value of each caravan Do you require legal protection insurance?

4 Other important information: If the answer to any of these questions is YES, please give full details. Have you, or any of the people named in this proposal, made any insurance claim in the last five years? Have you, or any of the people named in this proposal, in the last five years suffered any loss which would have led to a claim if you had been insured by the proposed insurance? (Include any losses at the home to be insured and at any previous home) Have you, or any of the people named in this proposal, ever been convicted of or are you now awaiting trial for any criminal offence? (You do not need to disclose motoring offences unless you were disqualified from driving or convictions which are spent under the Rehabilitation of Offenders Act) Do you have any current insurance? Please give the name of the insurers and the date when the policy expires. Has any insurer ever declined to provide you with insurance, imposed special terms for any insurance, cancelled or refused to renew any insurance? Is there any other information which might affect the risk of you suffering a loss which would be insured by the proposed insurance? When would you like the insurance to commence? In the space provided, please give any other material facts which might influence the acceptance or assessment of this proposal by insurers? If you are in any doubt whether a fact is material, you must disclose it? Declaration The facts and statements in this proposal form are true and accurate. I have given details of all material facts (A fact is material if it might influence the acceptance or assessment of this proposal by insurers). I understand that filling in this proposal does not commit me or insurers to enter into a contract of insurance, but if insurers do issue a certificate of insurance it will be on the basis of the information contained in this form. I understand that if any of the statements made in this form are incorrect or any material facts have not been given, any claim under any insurance certificate may not be paid. Please use this box to provide any additional information required Signature: Date: We will supply a copy of this proposal form on request if a Certificate of Insurance has been issued, but you should keep a copy of the form and of all other information you send to us. Data Protection Act Proposer's Consent Clause I/We hereby consent to any information you may have about me/us being processed by you for the purposes of providing insurance and claims handling, which may necessitate your providing such information to third parties. Signature: Date:

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