HOLMAN UNDERWRITING UNOCCUPIED PRIVATE DWELLINGS PROPOSAL FORM

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1 Holman Underwriting Policies Underwritten at Lloyd s London Underwriting Centre, 3 Minster Court, Mincing Lane, London, EC3R 7DD Tel: Fax: HOLMAN UNDERWRITING UNOCCUPIED PRIVATE DWELLINGS PROPOSAL FORM All questions must be answered in full where appropriate. Please complete all details and initial any alterations. You must take all reasonable care to provide complete and accurate answers to the questions we ask when you take out, make changes to, and renew your policy. Please note that if the information provided by you is not complete and accurate, we may: cancel your policy and refuse to pay any claim, or not pay any claim in full, or revise the premium and/or change any excess, or revise the extent of cover or terms of this insurance. Records should be kept of all information supplied (including copies of letters). No cover is in force until acceptance is confirmed and unless agreed otherwise this insurance is governed by English law. THE PROPOSER Proposer s full name (Mr/Mrs/Ms/Miss): Any Co-proposer s full name: (Mr/Mrs/Ms/Miss): Co-proposer s relationship to proposer:... Correspondence Address: Post code:... Daytime Tel No:... Mobile Tel No:.... Date of Birth: Proposer: Co-proposer:.... Nationality: Proposer:. Co-proposer:.... Occupation and industry including any part-time work. For example Sales Manager in an Advertising Agency not just Manager: Proposer:... Co-Proposer:.. What is the proposer s interest in the property (eg Owner, Executor):.. Are there any other legal interests: YES NO.. PROPERTY TO BE INSURED 1) Address of property to be insured: Post code:... HGF Unoccupied Householders Version UPD13001 Page 1 of 5

2 2) In what year was the property built: 3) Sum Insured (ie rebuilding costs plus debris removal, architect and surveyor fees): 4) Full description of the property to be insured (eg 2 storey house, bungalow):.. 5) i) Is the property): Detached Semi detached Terraced Other If other, please provide details below:. ii) If the property to be insured is attached to any other property please state if that property is occupied and give details of the condition of that property:.. 6) Please provide full details of the construction of the property (brick with tiled roof, timber framed, etc):.. Are Works to be carried out at the property: YES NO NOTE: Cover is NOT AVAILABLE if works are to be carried out at the property 7) Please indicate the overall condition of: i) The building: Good Fair Poor ii) The roof: Good Fair Poor If there are any flat areas please give details:. iii) Guttering, downpipes and drains: Good Fair Poor iv) Grounds: Good Fair Poor 8) What protections are there against intruders: i) On all external doors:. ii) On garage doors:... iii) On ground floor windows:.. iv) On other accessible windows (eg via a ladder): v) Any protections (eg sensor light):.. 9) Are there any basements or cellars: YES NO.... HGF Unoccupied Householders Version UPD13001 Page 2 of 5

3 10) Is the property within 250 metres of a stream, river, pond, lake or tidal water: YES NO 11) How long has the property been unoccupied:.. 12) How did the property become unoccupied (death, divorce, repossession, part exchange, etc):. 13) Is the property for sale: YES NO 14) Please provide details of persons who hold keys to the property: Name Address Reason why they hold the keys 15) i. How often and by whom is the property visited:. ii. Are these visits made on a voluntary basis or professionally under a contract: Voluntary Professional 16) Is there an individual with automatic authority to carry out necessary maintenance: YES NO.... OTHER INFORMATION 17) Has the proposer or anyone who this insurance will apply: a) Sustained within the last five years any loss or damage at any location from the perils to be covered by this insurance: YES NO b) Ever had a proposal for insurance declined, renewal refused, cover terminated, increased premium Required or special conditions imposed by any insurer: YES NO c) Ever been convicted of, or cautioned for (or charged but not yet tried with) any criminal offence other than motoring: YES NO d) Ever been made bankrupt or have a bankruptcy hearing pending: YES NO 18) Insurance to commence:.. HGF Unoccupied Householders Version UPD13001 Page 3 of 5

4 IF YOU NEED TO PROVIDE ANY ADDITIONAL INFORMATION PLEASE USE THE SPACE BELOW: DECLARATIONS A AND B BELOW MUST BE COMPLETED BEFORE COVER CAN BE GRANTED DECLARATION A The information you have provided in this form contains statements upon which Underwriters will rely when deciding whether to accept this insurance and the terms on which it may be offered, including the amount of premium payable. Should a contract be concluded this proposal will form the basis of the insurance. If you are in any doubt at all regarding any of the answers you have given, you should ask your broker I/We declare that 1. The Dwelling is in a good state of repair, will be so maintained and is not especially exposed to damage by Storm or Flood. 2. The sum to be insured represents and will be maintained at the full value of the property described. 3. The Property has not sustained any loss or damage from any of the perils for which this Proposal is made. You must tell us within 14 days of you becoming aware if any of the information provided by you changes after you purchase your policy and during the period of your policy. To the best of my knowledge and belief the information provided in connection with this proposal is true. I understand that any failure on my part to provide complete and accurate information, or any misrepresentation by me, may entitle the Underwriters to: cancel my policy and refuse to pay any claim, or not pay any claim in full, or revise the premium and/or change any excess, or revise the extent of cover or terms of this insurance. N.B If you wish to qualify any part of the Declaration please do so below: Proposer s Signature:. Date:... Co-proposer s signature:. Date: HGF Unoccupied Householders Version UPD13001 Page 4 of 5

5 DECLARATION B - TO BE COMPLETED BY ESTATE AGENT OR MANAGING AGENT OR INSURED I have visited the property proposed for insurance and following inspection can confirm the following: 1. The property is in sound condition and well maintained 2. All windows are entire and can be properly closed 3. All external doors are in good condition and can be properly locked 4. There are no particularly adverse features to concern Underwriters (e.g. derelict area, nearby property vandalised, graffiti or slogans on walls, etc) Name:.. Position Held:... Name of Firm: Type of Business (eg Estate Agent):.. Telephone Number:.. Date Visited:.. Address: Post code:... Signed:.. IF YOU WISH TO QUALIFY THIS DECLARATION IN ANY WAY PLEASE DO SO BELOW: Date:... Holman Underwriting is a trading name of John Holman & Sons Ltd who are acting as agents of and bind cover for Insurers London Underwriting Centre, 3 Minster Court, Mincing Lane, London, EC3R 7DD Tel: Fax: John Holman & Sons Ltd Head & Registered Office as above Registered in England No Authorised and regulated by the Financial Conduct Authority FRN HGF Unoccupied Householders Version UPD13001 Page 5 of 5

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