Park Home Insurance. Proposal Form. Please complete ALL sections and ensure all sections are filled in accurately otherwise cover could be refused.

Transcription

1 Park Home Insurance Proposal Form Please complete ALL sections and ensure all sections are filled in accurately otherwise cover could be refused. Please post or fax your completed form to: Jenna Smith Omar Insurance Portwell House Faringdon Oxon SN7 7HU Fax: Are you a Broker/Intermediary: * Please confirm you are an FCA registered Intermediary/Broker: Details Company Name Contact Name Phone Number 1

2 Your Information Personal Details * First Proposer Second Proposer Title Name Surname Date of Birth Occupation (if retired please state "Retired" and former occupation) Insured Address * Street Address Street Address Line 2 City County United Kingdo m Postcode Country Phone Number: 2

3 Park Details Is your Property on: * 1. BH&HPA Registered Residential Park 2. NCC Registered Residential Park 3. Gold Shield Registered Park 4. David Bellamy Conservation Awarded Park 5. Unregistered Permanent Residence Park 6. Private Land (Permanent Residence) 7. Private Land with Construction Works 8. Farm 9. Other, business premises If you answered YES to. 9, please provide details: Park Operator's Business Name: Park Operator's Contact Name: First Name Last Name Park Operator's Phone Number: Park Operator's 3

4 After Investigation, please advise if the park has suffered any claims caused by: * Subsidence Storm Damage Flood Prevailing Damaging Winds If yes, please detail claims: 4

5 Home Details About the Home * Details Make Model Chasis/Serial. Year of Manufacture Length (feet) Width (feet) Please te If your Home is over 20 years old special terms and conditions may be applied to your Policy to ensure the Home remains compliant with current safety standards. Have you previously held insurance on this property?: * If YES, please detail which Insurance Company: Please state expiry date of current policy: Have you made a claim in the last 5 years?: * 5

6 If YES, please advise type of claim(s): 1. Accidental Damage 2. Back-up of Drains 3. Fire Flood Liability 4. Personal Accident 5. Storm 6. Theft 7. Vandalism 8. Water Damage 9. Other If you answered YES to. 9, please provide details: e.g. date and brief description of incident and final settlement amount Have you or anyone living with you ever: * Been convicted or charged with any offence other than driving offences Been made bankrupt or have any unresolved CCJs Been refused insurance or had special terms imposed If YES, please provide details: 6

7 More About your Park Home Is your Property: * 1. Manufactured to BS3632 Standard? 2. Is your Property a Twin Unit? 3. Under a Manufacturer Supplied Warranty? 4. Gold Shield Warranty 5. Platinum Seal 6. Other If your Property is under a Manufacture Supplied Warranty please provide details here: e.g. Name of warranty supplier, length and type of cover supplied If you selected "6. Other", please provide details here: Is your Property likely to be unnocupied for more than: * 30 consecutive days 3 consecutive days between 31st October - 31st March 7

8 Please confirm that: * You have complied with and will continue to comply with the conditions of the Manufacturer's Owner's Handbook & Warranty Obligations The base has been installed in accordance with the manufacture's:- Siting Instructions & Warranty Code of Practice If a twin unit, the supplier has installed the home in accordance with the manufacturer's:- Siting Instructions & Warranty Code of Practice Please confirm the type of heating & hot water you have: * Gas Electric Solid Fuel Please provide details of any modifications to your home: 8

9 Insurance Cover Required Section One: Building & Contents Insured Values * Amount New Replacement Value Resiting Costs Total Contents Value Family Legal Solutions Policy For an additional 15 (including insurance premium tax) we recommend the Family Legal Solutions Policy to cover additional legal expenses. Please read the Family Legal Solutions Policy Summary for details Please indicate if you would like to to be quoted without this policy: I would not like the Family Legal Solutions Policy included in my quote Freezer / Refrigerator Contents: Up to 100 Freezer / Refrigerator Contents Cover is included aut omat ically. ( Please only specify any additional cover required.) Freezer / Refrigerator Contents Additional Cover Amount ( ): 9

10 Section Two: Insurance for Selected Items Away From Home Cover: Anywhere within Europe. Anywhere within the Rest of the World for a maximum of 30 days. Selected items are also covered within the boundaries of T he Home. Away from Home Cover: Personal Money & Credit/Debit Cards* Personal Effects & Clothing** Amount ( ) Sports Equipment Pedal Cycles Valuables*** Informat ion Box: * Personal Money & Credit / Debit Cards: We provide cover for loss & subsequent fraudulent use of credit / debit cards anywhere in Europe. ** Up t o 250 of Personal Effect s and Clot hing is aut omat ically included. *** Any items with a value above 400 should be listed separately under Specified Valuables. Specified Valuables (please detail item and replacement value): 10

11 Declarations Import ant: list of questions can be exhaustive and we must ask you to consider carefully whether there is any information not given herein which could influence the insurer's acceptance of this proposal. Material information includes any special, unusual or otherwise relevant features of the property, its occupation or its location which might make losses more likely to happen or to be more serious or costly than might otherwise be anticipated. You should disclose any information which might be relevant. Failure to do so could invalidate your policy. Declarat ion: I declare that to the best of my knowledge and belief that the answers herein are true and that all material information has been fully disclosed. I agree that this proposal is for insurance in the normal terms and conditions of the insurer's policy and shall be incorporated into and form part of the insurance contract. I undertake to inform insurers, in writing and immediately, of all changed before and during the policy period. t ice: The information provided on this proposal form will be made available to any other insurer, broker or authority who might make an enquiry regarding the veracity of statements made regarding the information provided in any proposal form, claim form or other document or any statement made orally or electronically. Declaration I acknowledge that the information here-in is true and correct and forms the basis on which the insurance is provided. Date Form Completed: Signature: Bordengate Insurance and BGi.UK are trading styles of H J Roelofs (UK) Ltd which is authorised and regulated by the Financial Conduct Authority (FCA). Oour Financial Services register num ber is Com pany Registration no