Camberford Law plc PROPOSAL FORM. Innovative Insurance Solutions Since 1958

Transcription

1 A UNIQUE AND COMPREHENSIVE INSURANCE SCHEME FOR UNOCCUPIED PROPERTY PROPOSAL FORM Camberford Law plc Innovative Insurance Solutions Since 1958 Insurance Brokers Underwriting Agents Authorised and Regulated by the Financial Services Authority Lygon House, 50 London Road Bromley, Kent, BR1 3RA Telephone: Facsimile: Website: 1

2 UNOCCUPIED BUILDINGS PROPOSAL FORM ****(All questions must be answered)**** 1. Name of Proposer and Trading Title (if any) 2. Your Address Post Code Fax Telephone Address 3. Address of the premises to which this Insurance will apply Post Code 4. If you are not the owner please indicate interest 5. Proposer s Business Description 6. Describe the premises : (i) Are they: House Flat Shop Office Industrial Other (please describe) (ii) Are they: Terraced semi-detached Detached (iii) Number of Floors (iv) Approx. age (v) Approx. size (vi) Are the premises Grade Listed? If so, please state which Grade 7. State Construction: (a) External walls of the building (b) Roof (c) Are there areas of non-standard construction (e.g. Flat Roofs), if so please describe: - (d) Are the buildings free from signs of damage due to subsidence, heave or landslip (such as internal or external cracks), and not in an area where there has been or is evidence of these causes 2

3 (e) Are/Have the Buildings ever been monitored for or subject to Landslip, Subsidence or Heave? (f) If YES, please provide full information including Survey Reports and Structural Engineers Reports in addition to this Proposal Form (g) Are you aware that any neighbouring buildings have been the subject of an occurrence of subsidence, heave or landslip? (h) Have the buildings been extended within the last 25 years? If YES, please give details (I) Are there any trees or shrubs within 7 metres (22ft) of the premises (whether inside or outside the garden) which are more than 3 metres (10ft) tall? If YES, please give details including type of tree, height and distance 8. SECURITY AND UNOCCUPANCY ARRANGEMENTS Please confirm the following: (Residential and Commercial Premises) (I) All external doors are fitted with 5 lever mortise deadlocks or similar security locks or Fastenings and all opening windows are fitted with window locks or double glazing? If NO, describe arrangements in details here (ii) The supply of gas and electricity to the premises has been disconnected (with the exception of electricity required for maintaining burglar and fire alarms) OR Central Heating is maintained at a minimum temperature of 60 degrees F during the period 1 st November to 1 st April (iii) The premises are inspected at least once every seven days by the owner or his representative and a signed/dated log is kept Applicable to Shops, Offices and all other commercial premises in addition to the above:- (iv) The entire shop or office front including doors are fitted with external shutters, grilles or the entire area is boarded up (v) All other ground floor windows and accessible upper floor windows are barred or grilled at four inch centres or alternatively boarded up (vi) All letter boxes and other similar openings are sealed 3

4 (vii) All loose combustible material to be kept clear of the property Applicable to all premises (viii) Are there any other security features (such as alarms) If YES, describe in detail here (ix) Approximately how far to nearest responding fire station Miles (x) If NO answered to any question, then please explain arrangements in details here (xi) Is there a Caretaker residing on the premises 24 hours per day (xii) Please submit a photograph of the premises if available. 9. ADJACENT PROPERTY (I) Is adjacent property: Occupied Partially occupied Not at all (ii) If adjacent property occupied for what occupations (state if residential) 10. YOUR PREMISES (I) Please indicate the reason why the premises are unoccupied (ii) How long has premises been unoccupied prior to this application? 11. Are the premises: For Sale To Let To Be Redeveloped To be Demolished Other (please describe) 12. Interest Clause Do you require any Bank, Building Society or other person s interest to be noted on the Policy? If so please indicate below 13. (a) Name of Previous Insurers (if known) (b) Date of expiry of policy Policy No (c) Has any insurer declined to accept, cancelled, refused to continue or agreed to continue only on special terms, any insurance for the Proposer or any other person to whom this insurance will apply? 4

5 If YES, please give details 14. Has the Proposer, or any other person whose property is to be Insured hereunder sustained any loss or damage which would have been covered by this type of insurance had it been in force? If YES state: (a) Approximate date of each loss or damage (b) Circumstances and amount claimed 15. Has the Proposer had any criminal convictions that would be considered material fact or relevant to this Insurance. Please provide date and details of conviction, together with fine imposed. STATEMENT OF VALUE It is important that you should ensure the value given below is adequate, as under-insurance may reduce the amount recoverable in the event of a claim. State value to be insured (a) Buildings (Full cost of reconstruction in their present form) This amount must include all outbuildings, garages, domestic oil and gas Pipes, domestic fuel, oil tanks, swimming pools, tennis courts, drives, patios, Terraces and walls (b) Fixture and Fittings (excluding Personal effects and Contents) 5

6 THE DECLARATION I/We declare that to the best of my/our knowledge and belief: 1 The premises are and will be kept in a good state of repair. 2 The Sums Insured represent the full values. 3 Neither I nor any person whose property is to be insured have been charged with or convicted of arson or ant offence involving dishonesty of any kind (e.g. fraud, robbery, theft or handling of stolen goods). I/We agree that the information provided in connection with this proposal whether in my hand or not is true and I have not withheld any material facts. I/We understand that non-disclosure or misrepresentation of a material fact will entitle the Underwriters to void this insurance. (N.B A material fact is one likely to influence acceptance or assessment of this proposal by Underwriters) IF YOU ARE IN DOUBT AS TO WHAT CONSTITIUTES A MATERIAL FACT YOU SHOULD CONSULT YOUR BROKER/AGENT. I/We understand that the signing of this proposal does not bind me/us to complete this insurance but agree that should a contract of insurance be concluded, this proposal and the statements made therein shall form the basis of the contract. Signature of Proposer Date Date cover required from Please note no cover is in force until the Underwriters have accepted this fully completed proposal form. 6

7 SUBSIDENCE QUESTIONNAIRE (Must be completed for Subsidence cover to be provided and remain in force) FULL NAME ADDRESS OF PROPERTY TO BE INSURED Post code TICK BOX YES NO 1. Are the above buildings built on clay soil? 2. Are the above buildings built on made-up ground or in a land fill site? 1. Are the above buildings built on a hillside? 2. Are there any visible cracks in the walls of the building? (a) between 2.5 mm and 5 mm wide (b) more than 5 mm wide? 3. Are any Mine or Quarry workings (operational or disused) within one mile of the buildings? 4. What is the age of the Building? 5. Were the premises originally built to be used as a Private Dwelling House? 6. Are there any trees and shrubs within 20 metres (65ft) of the buildings which are more than 5 metres (15 ft) tall? If YES please indicate below the distance of nearest tree/shrub from the building (a) 10m 20m (32ft 65ft) (b) 5m 10m (16ft 32ft) (c) less than 5m (16ft) 7. Have these buildings experienced any previous subsidence damage? If YES, please give details DECLARATION. I declare that the foregoing statements and particulars are true and complete to the best of my knowledge and will form the basis of the contract. I agree to accept Insurance subject to the terms and conditions of the Company s Policy and that the Insurance will not be in force until confirmation has been given by the Company 7