Towergate Platinum Home Insurance Proposal Form

Transcription

1 Towergate Platinum Home Insurance Proposal Form

2 Platinum Home Proposal Form PLEASE COMPLETE IN BLOCK CAPITALS It is essential that every question is completed and that you give full and true answers. If you do not do so, your insurance may not protect you in the event of a claim. A specimen policy is available on request. A. Your Personal Details Day Month Year A. Date from which insurance is to start B. Proposer Mr/Mrs/Miss/Ms Initials Surname Spouse/Partner C. Date of Birth Proposer Spouse/Partner D. Occupation(s) Proposer Spouse/Partner (Give full details including any part-time employment avoiding the use of such terms as Director, Manager or Shop Proprietor) E. Postal Address House number and Street Town County Postcode F. Telephone No. Home (inc STD) Business (inc STD) Name G. Additional building interest if any e.g. Bank or Building Society Address County Postcode Roll Number H. Address of property to be insured if different from above House number and Street Town County Postcode Please indicate reasons for different address (a) Will you be occupying the property from the date cover is to commence? Yes No (b) Are you the owner of the property? Yes No If you have ticked a tinted box above please give full details here or separately I. Name of previous insurer (State none if you have not previously held a policy) J. In respect of any of the risks proposed have you or any member of your family normally residing with you (a) suffered any losses or made any claims during the last five years whether insured or not? Yes No (If yes, please complete losses or claims box on next page) (b) been refused insurance or had special terms or conditions applied by any insurer? Yes No (c) ever been convicted of or charged (but not yet tried) with any criminal offence (other than a motoring offence)? Yes No (d) ever been declared bankrupt or been the subject of bankruptcy proceedings? Yes No (The proposer is not required to include convictions regarded as Spent by virtue of the Rehabilitation of Offenders Act 1974) 2 Platinum Home

3 For (a) previous losses or claims Date of Loss Type of claim e.g. storm Amount of Loss/Claim For (b) (c) (d) B. About your Property K. Please tick all relevant boxes Detached Semi-Detached Terraced House Bungalow Flat (*) Please be as accurate as possible with the question Date Built as the rates applied depend on the age of your property L. Please complete fully Number of Bedrooms Date Built (*) Is the property a listed building? (If Yes, state grade) No M. Property details (a) (i) (ii) construction of walls construction of roof (iii) Does your property have a flat roof? (If yes, state percentage) Yes No (b) in a good state of repair and it will be so maintained at all times? Yes No (c) self contained (i.e. no shared facilities) with your own separate lockable entrance? Yes No (d) fitted with any smoke alarms? Yes No (e) used solely as private living accommodation for you and your family? (see Let Property Details on next page) Yes No (f) currently occupied? Yes No (g) regularly left unattended at any time (other than for normal employment, holiday or shopping purposes)? Yes No (h) left unoccupied or unfurnished for more than 60 consecutive days at any one time? Yes No If you have ticked any of the tinted boxes, please give full details here or separately. Platinum Home 3

4 N. (a) Has the property ever been damaged by Flood? Yes No (b) To the best of your knowledge and belief is there any history of Flood in the area? Yes No If you have ticked any of the tinted boxes, please give full details here or separately. O. (a) (i) Has the property ever been underpinned, repaired or restored in connection with or suffered from damage by Subsidence, Ground Heave or Landslip? Yes No (ii) Are there any signs of damage to the property caused by Subsidence, Ground Heave or Landslip (such as internal or external cracks)? Yes No (b) To the best of your knowledge and belief is there any history of Subsidence, Ground Heave or Landslip in the area? Yes No (c) Is the property the subject of a valuation or survey report which mentions settlement or movement of buildings or recommends further investigation? (if Yes please supply a copy of the report with this proposal) Yes No If you have ticked any of the tinted boxes, please give full details here or separately. Let Property Extension If you have ticked the tinted box on question e (from previous page) and the property is to be let, cover may be granted provided that you are able to confirm the following conditions: 1. The tenancy agreements are for a minimum of 6 months 2. The property is to be occupied by a family, a married or common law couple, a single person or a maximum of two unrelated persons sharing 3. The property is NOT to be occupied by students, the unemployed or DSS, Local Authority or charity referrals nor let to local authorities or housing associations. Please confirm the above by ticking the appropriate box Yes No Notes The standard excess is increased to 125 and Accidental Damage and Personal Possessions cover cannot be granted C. Security The policy will be subject to a specific Let Property endorsement a copy of which can be obtained from your insurance advisor (a) The main entrance and exit doors are fitted with a lock carrying the kitemark sign of approval or by a mortice Yes No deadlock having a minimum of 5 levers. Other external doors including sliding patio doors are fitted with the above or fitted top and bottom with key-operated security devices in addition to existing locks. All accessible windows/skylights and fanlights are fitted with key operated security devices. (b) A burglar alarm system is in use and is installed and maintained by a National Security Inspectorate (NSI) or a Security Systems and Alarms Inspection Board (SSAIB) approved installer. Please provide an alarm specification. Yes No (c) I/We confirm that the property is regularly occupied during the daytime. Yes No Note: In certain postcodes, security devices are mandatory. Your broker will provide full details if this is the case. 4 Platinum Home

5 D. Buildings Section index linked. Minimum sum Insured 100,000 Please tick appropriate boxes Is insurance required? Yes No Blue shaded sections to be completed by your INSURANCE ADVISOR Level of Cover: Standard Accidental Damage (a) If YES state sum to be insured (b) A 50 standard policy excess applies to the Buildings. Do you wish to reduce your premium by voluntarily accepting responsibility for a further: Note: Any voluntary excess will be added to the 50 standard policy excess. E. Contents Section index linked. Minimum sum insured 50,000 Please tick the appropriate boxes PREMIUM Is insurance required? Yes No If YES state sum to be insured DO NOT INCLUDE ANY PROPERTY INSURED UNDER THE PERSONAL POSSESSIONS SECTION. (a) Does the replacement cost of all Valuables exceed 40% of the total Contents sum Insured and does jewellery exceed 12,500? (see definition at the bottom of this page) Yes No DO NOT INCLUDE VALUABLES INSURED UNDER THE PERSONAL POSSESSIONS SECTION. (b) Does the replacement cost of any one Valuable item exceed 5% of the Contents sum insured Yes No If you have ticked any of the tinted boxes, please give full details here or separately. (c) Do you wish to include the Accidental Damage extension? Yes No (d) A 50 standard policy excess applies to the Contents Section. Do you wish to reduce your premium by voluntarily accepting responsibility for a further: PREMIUM Note: Any voluntary excess will be added to the 50 standard policy excess. Deep freezer contents up to 1,000 covered automatically under the Contents Section F. Personal Possessions Section index linked only available if Contents have been insured Please refer to your insurance advisor for items which must be specified or are excluded from cover. Personal Possessions Cover An amount of Unspecified Personal Possessions cover is automatically included and charged for separately. The amounts shown are listed below: Automatic amount of Contents Sum Insured Personal Possessions Cover Single Article Limit 50,000-74,999 2,500 1,500 75,000-99,999 5,000 1, , ,999 7,500 3, , ,000 10,000 3,000 If you wish to choose a higher level of personal possessions cover, please state sum to be insured in box. Specified Items Please submit current evidence of value for individual items over 2,500. Please give full description below of all specified items to be insured Sum insured Please list on a separate sheet if more than 3 items. PREMIUM Platinum Home 5

6 Money Up to 1,000 or 2,500 if kept in an approved safe. This cover is given automatically under the Contents Section. Credit Cards Up to 5,000. This cover is given automatically under the Contents Section. A 50 standard policy excess applies to the Personal Possessions Section. Valuables Jewellery up to 12,500, watches, clocks, furs, articles made of precious metal, precious stones, cups and trophies, personal computers, cameras, video cameras and their equipment and accessories, binoculars and telescopes, pictures, works of art and collections of stamps, coins and medals. G. Pedal Cycles Section not index linked Is insurance required? Yes No If YES please complete Section below Pedal Cycles Cycle 1 Sum insured Cycle 3 Sum insured Cycle 2 Sum insured Cycle 4 Sum insured PREMIUM Complaints Procedure Premium plus Insurance Premium Tax at the current rate Total Policy Premium We, Towergate Underwriting Household, a trading name of Towergate Underwriting Group Limited, act for a consortium of leading UK insurers who underwrite your policy. However, should you have a complaint, please initially notify Towergate Underwriting Household. All details of our complaints procedure will be set out in your policy booklet. The complaints procedure operated either by us or the insurers does not affect your statutory or other rights to legal recourse. Choice of Law The law of England and Wales will apply to this contract unless: 1) You and the Insurer agree otherwise; or 2) At the date of the contract you are a resident of (or, in the case of the business, the registered office or principal place of business is situated in) Scotland, Northern Ireland, Channel Islands or the Isle of Man, in which case (in the absence of agreement to the contrary) the law of that country will apply. Data Protection Act Information Uses For the purpose of the Data Protection Act 1998, the Data Controller in relation to any personal data you supply is the consortium of insurers as detailed in the Policy Summary and Towergate Underwriting Group Limited trading as Towergate Underwriting Household. Insurance Administration Information you supply may be used for the purposes of insurance administration by the insurer, its associated companies and agents, by reinsurers and your intermediary. It may be disclosed to regulatory bodies for the purposes of monitoring and/or enforcing the insurer s compliance with any regulatory rules/codes. Your information may also be used for offering renewal, research and statistical purposes and crime prevention. It may be transferred to any country, including countries outside the European Economic Area for any of these purposes and for systems administration. In assessing any claims made, the insurer or its agents may undertake checks against publicly available information (such as electoral roll, county court judgements, bankruptcy or repossessions). Information may also be shared with other insurers either directly or via those acting for the insurer (such as loss adjusters or investigators). With limited exceptions, and on payment of the appropriate fee, you have the right to access and if necessary rectify information held about you. 6 Platinum Home

7 Credit Searches and Accounting In assessing your application, the insurer may search files made available to it by credit reference agencies who may keep a record of that search. The insurer may also pass to credit reference agencies information it holds about you and your payment record. Credit reference agencies share information with other organisations, enabling applications for financial products to be assessed or to assist the tracing of debtors or to prevent fraud. The insurer may ask credit reference agencies to provide a credit scoring computation. Credit scoring uses a number of factors to work out risks involved in any application. A score is given to each factor and a total score obtained. Where automatic credit scoring computations are used by the insurer, acceptance or rejection of your application will not depend only on the results of the credit scoring process. Sensitive Data In order to assess the terms of the insurance contract or administer claims which arise, the insurer will need to collect data which the Data Protection Act defines as sensitive (such as medical history or criminal convictions). By proceeding with this application you will signify your consent to such information being processed by the insurer or its agents. Marketing Insurers and their agents may use your information to keep you informed by post, telephone, or other means about products and services which may be of interest to you. Your information may also be disclosed and used for these purposes after your policy has lapsed. If you do not wish your information to be used for these purposes please write to Towergate Underwriting Household, Towergate House, St Edward s Court, London Road, Romford, Essex, RM7 9QD. Fraud Prevention and Detection In order to prevent and detect fraud we may at any time: Share information about you with other organisations and public bodies including the Police; Check and/or file your details with fraud prevention agencies and databases, and if you give us false or inaccurate information and we suspect fraud, we will record this. We and other organisations may also search these agencies and databases to: Help make decisions about the provision and administration of insurance, credit and related services for you and members of your household; Trace debtors or beneficiaries, recover debt, prevent fraud and to manage your accounts or insurance policies; Check your identity to prevent money laundering, unless you furnish us with other satisfactory proof of identity; Undertake credit searches and additional fraud searches. We can supply on request further details of the databases we access or contribute to. Claims History Under the conditions of your policy you must tell us about any Insurance related incidents (such as fire, water damage, theft or an accident) whether or not they give rise to a claim. When you tell us about an incident we will pass information relating to it to a database. We may search these databases when you apply for insurance, in the event of an incident or claim, or at time of renewal to validate your claims history or that of any other person or property likely to be involved in the policy or claim. You should show these notices to anyone who has an interest in property insured under the policy. Important Notes Please read the following Important Notes and Declaration carefully before signing and dating the Declaration. 1. All material facts must be disclosed. Failure to do so could invalidate the policy. A material fact is one which is likely to influence an insurer in the acceptance and assessment of this application e.g. intended unoccupancy of the property or any criminal convictions (other than motor offences). If you are in any doubt as to whether a fact is material then it should be disclosed to the insurer. If any changes in circumstances arise during the period of insurance cover please provide your insurer with details. 2. A specimen copy of the policy wording is available on request. We recommend you keep a record (including copies of letters) of all information provided to the insurer for your future reference. A copy of the completed application form will be supplied on request within a period of three months after its completion. 3. For our joint protection telephone calls may be recorded and/or monitored. Platinum Home 7

8 Declaration I/We understand the contents of this completed application and I/we declare that the information given is, to the best of my/our knowledge and belief correct and complete and that the Sums Insured represent the full value of the property. I/We agree that the statements in this application shall form the basis of the contract between the insurer and myself/ourselves and if the risk is accepted I/we undertake to pay the premium when called upon to do so. I/We understand that my/our information may also be disclosed to regulatory bodies for the purposes of monitoring and/or enforcing the insurer s compliance with any regulatory rules/codes. I/We also declare that if anything on this form was written by another person, he or she acted as my/our agent and not for the Company for this specific purpose. I/We apply for a contract of insurance between the insurers and myself/ourselves and agree to accept the policy when issued and conform to the terms of the policy when issued. WARNING: Before signing this proposal form please read the Important Notes and the Declaration above and ensure all questions have been answered correctly and accurately. You must declare the full value of property insured. Failure to do so may invalidate your policy or reduce claims settlements. Underwritten by a consortium of leading UK insurers as detailed in the Policy Summary. Proposer s Signature Joint Proposer s Signature Date of Proposal Date of Proposal The company reserves the right to decline any proposal or to impose special terms. (Note: if forms are being completed by Joint Proposers both signatures are required before cover can be effective) Towergate Underwriting and Towergate Underwriting Household are trading names of Towergate Underwriting Group Limited Towergate House, St Edward s Court, London Road, Romford, Essex RM7 9QD Tel: Fax: household@towergate.co.uk Registered Office: Towergate House, Eclipse Park, Sittingbourne Road, Maidstone, Kent ME14 3EN Registered in England No Authorised and regulated by the Financial Services Authority 6386/157/PF/11.11/13448