Home Solutions Insurance Proposal form
Home buildings and contents insurance IMPORTANT Please read before completing this form. Please complete this form in block capitals giving full answers. Tick boxes where appropriate. If answer space is insufficient, please continue on a separate sheet of paper. If the house is jointly owned, please give the name of each owner. Agents Reference Policy Number (to be completed by Zurich) 1 Proposer You 1. First name(s) 2. Surname Mr Mrs Miss Ms Dr Other (please give details) Your partner/joint proposer First name(s) Surname Mr Mrs Miss Ms Dr Other (please give details) 3. Postal address Town County Postcode Daytime tel no. (inc STD) Evening tel no. (inc STD) 4. If the property to be insured differs from above, please state the address and reason for the difference. Address of the house to be insured Town County Postcode Is the reason for the difference due to a forthcoming change of address? Yes No If yes, when will the postal and risk address become the same? / / If no, please give full details 5. You Your partner/joint proposer Age Date of birth Age Date of birth 6. Your occupation including any part-time work Nature of employer s business (or own if self-employed) 7. What date do you require cover from? / / 8. If you are not currently insured with us, please state: a) Contents: Name of previous insurer Policy no/reference Renewal date / / b) Buildings: Name of previous insurer Policy no/reference Renewal date / / 9. If you are already insured with us, please complete the following: a) Existing policy number b) Is this proposal for: an additional home? Yes No a change of home/address? Yes No additional policy cover? Yes No c) If the current policy is to be cancelled please state effective date / / 2
2 General questions Construction/type 10. Are the external walls of your home built of brick, stone or concrete? Yes No 11. Is 80% or more of your home roofed with slates, clay or concrete tiles, concrete or metal? Yes No 12. Is your home a: a) Detached house? b) Semi-detached house? c) Terraced house? d) Detached e) Semi-detached f) Terraced bungalow? bungalow? bungalow? g) Flat/maisonette? h) Other? (Please specify) 13. How many bedrooms does your home have? 1 2 3 4 5 (this should include any room originally built to be a bedroom even if now used for other purposes) 14. In what year was your home built? 15. Does your home have a gas central heating system? Yes No Condition/area 16. Is your home, (including garage): a) in a good state of repair? Yes No b) showing signs of movement (e.g. cracking or bulging of walls) which could be Yes No attributable to subsidence, heave or landslip? c) in a locality where there is evidence or a history of subsidence, heave, Yes No landslip or flooding? d) situated less than ¼ mile/400 metres from the nearest river, watercourse or sea? Yes No If Yes, please state the height of your home above the normal high water level feet/metres e) currently undergoing renovation or construction work? Yes No f) fitted with at least one smoke detector? Yes No 17. Has your home (including garage) sustained previous damage by subsidence, Yes No heave or landslip? Occupancy/use 18. Is your home: a) owned and occupied by you? owned by you and let unfurnished? owned by you and let furnished? rented furnished from a private landlord? rented unfurnished from a private landlord? other Please give details b) self contained? (i.e. having a separate and private entrance under Yes No your sole control) c) occupied by anyone other than you or your relatives? Yes No d) to be lived in from the commencement date of this insurance? Yes No e) used for any business purposes other than clerical? Yes No (This includes any garage or outbuildings) f) likely to be left unoccupied for more than 60 days at a time? Yes No g) a weekend or holiday home? Yes No h) normally unoccupied throughout the day? Yes No 19. Please state: a) the total number of occupants of your home b) the number of occupants aged under 18 3
Personal history 20. Have you or any member of your family sustained any loss or damage or had Yes No claims made against you for the cover being requested during the last 3 years? If yes, give details of all incidents wherever they occurred even if not covered by insurance: Policy type (Buildings or Contents) Cause of loss (storm, theft, etc.) Date Cost / / / / / / 21. Are you claiming a No Claim Discount? Yes No (If so, question 8a and/or 8b must be fully completed) If Yes, indicate number of consecutive years free of Contents claims to date 0 1 2 3 4 5 or more If Yes, indicate number of consecutive years free of Buildings claims to date 0 1 2 3 4 5 or more 22. Have you or any member of your family been refused insurance or Yes No had special terms imposed? 23. Have you or any person living in your home been convicted of, Yes No or received a police caution for any criminal offence (other than motoring offences) or is there any prosecution pending? 24. Do you or does any person living in your home smoke? Yes No 25. Are you or any member of your family engaged in the Yes No entertainment profession in any way? If you have ticked any of the shaded boxes in answer to questions 10-25, please give details: Question number Additional information (please continue on a separate sheet if necessary) Security 26. a) Is your home protected by the door and window locks and bolts Yes No described in the prospectus? b) Is your home protected by an intruder alarm system installed Yes No and maintained by a NSI or SSAIB recognised firm? c) Are you a member of a police approved Neighbourhood Watch Scheme? Yes No 4
3 Contents insurance (If Contents Insurance is not required please proceed to question 30) Cover for Contents is only available for homeowners or tenants of properties rented unfurnished from private landlords. You may find it useful to refer to our prospectus before completing the following questions. We may require your home to be protected by the door and window locks and bolts described in the prospectus and these must be put into operation when the home is unattended or at night (other than occupied bedrooms). Your insurance adviser will advise you if this is the case. 27. a) Amount to cover the full replacement cost of your contents b) Please state below any valuables (gold, silver or other precious metal, jewellery, watches, furs, pictures or other works of art, collections of stamps or coins) which exceed 2,500 in value: (valuations or receipts must be provided for any articles valued over 5000). Do not include any article insured separately under Personal Possessions. 1 2 3 c) If the total amount of valuables exceeds 40% of the contents sum insured, please state the total value of such items d) Do you wish to upgrade to Accidental Damage cover? Yes No e) You may increase the standard excess to 150 or 250 in return for a premium discount. If a higher excess is required, please tick the 150 250 appropriate box: Contents options Personal possessions 28. a) Do you require cover for Unspecified Personal Possessions? The standard Yes No Contents excess applies. (see prospectus for the description of articles insured under this heading). If cover is required on any article which exceeds 1,500 or pedal cycles valued at more than 500, these should be shown under Specified Personal Possessions. b) Is the standard cover of 2,000 for Unspecified Personal Possessions sufficient Yes No for your needs? If No, indicate the level of cover required: 3,000 4,000 5,000 6,000 c) Specified Personal Possessions: Please describe below articles valued at more than 1,500, or pedal cycles valued at more than 500, which are to be specifically insured and state the sum to be insured. (Valuations or receipts must be provided for any articles valued over 5,000). 1 2 3 Please continue on a separate sheet if necessary. Caravan 29. a) Do you wish to include Caravan cover? Yes No Cover is only available for touring caravans not more than 15 years old. b) Make Model Year of make c) Please state the current market value of the caravan (together with its fixtures and fittings, awnings, furniture, furnishings, utensils and household linen in the caravan) 5
4 Buildings insurance 30. a) Please state the sum to be insured (this should represent full rebuilding cost as new). b) Is your home a listed building? Yes No (If Yes, please provide a recent professional valuation) c) Do you wish to upgrade to Accidental Damage cover? Yes No d) You may increase the standard excess to 150 or 250 in return for a premium discount. If a higher excess is required, please tick appropriate box. 150 250 e) Name of mortgagee (Building Society, Bank, etc.) Address of branch office Roll No./Ref No. Postcode Buildings options 31. Do you wish to include Garden Cover? Yes No Buildings or Contents options 32. Do you wish to include Family Legal Expenses? Yes No 5 Payment details 33. Indicate, by ticking one box, how you wish to pay your premium (see full details on page 7). Annually Monthly by Direct Debit 6 Important notes Zurich Insurance plc holds your details in accordance with the Data Protection Act 1998. Policy Administration In order to administer your insurance policy and any claims made against the policy, Zurich Insurance plc may share personal data provided to us with other companies within the Zurich Insurance Group and with business partners, including outside the European Economic Area (EEA). If we do transfer your personal data, including where we propose a change of underwriter, we make sure that it is appropriately protected. Product & Services Unless you have advised us otherwise, we may share personal data that you provide within the Zurich Insurance Group and with other companies that we establish commercial links with so we and they may contact you (by mail, e-mail, telephone or other appropriate means) in order to tell you about carefully selected products, services or offers that we believe will be of interest to you. If you do not wish us to do this please tick the box. You must tell us immediately if at any time any of the information on which this insurance is based is incorrect or changes, for example, you or any person in your home having a conviction, pending prosecution or police caution for any offence other than driving offences or change of occupancy (e.g. property let to third party) or occupation. Failure to do so may result in your insurance no longer being valid and claims not being met. If in doubt about any change, please let us know. The changes, if accepted by us, will apply from the date indicated on your updated schedule. In this case we will be entitled to vary the premium and terms for the rest of the period of insurance. You should keep a record (including copies of letters) of all information supplied to us in connection with this insurance. A copy of this completed proposal form will be supplied to you on request within a period of 3 months after its completion. Fraud Prevention & Detection In order to prevent and detect fraud, we may at any time: Share information about you with other organisations including the Police, undertake credit searches, check and/or share your details with fraud prevention and detection agencies. 6
If false or inaccurate information is provided and fraud is identified, details will be passed to fraud prevention agencies. Law enforcement agencies may access and use this information. We and other organisations may also access and use this information to prevent fraud and money laundering, for example, when checking details on applications for credit and credit related or other facilities, managing credit and credit related accounts or facilities, recovering debt and tracing beneficiaries, checking details on proposal and claims for all types of insurance or checking details of job applicants and employees. Please contact us on the number shown on your policy documentation if you want to receive details of the relevant fraud prevention agencies. We and other organisations may access and use from other countries the information recorded by fraud prevention agencies. 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 any 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 this notice to anyone who has an interest in the property insured under the policy. The information supplied to us by you may be held on computer and passed to other insurers for underwriting and claims purposes. Your cancellation rights If you decide that you do not want to accept the policy (or any future renewal of the policy by us) tell us (or your insurance adviser) of your decision, in writing or by phone using the contact details provided on the covering letter within 14 days of receiving the policy (or for renewal, within 14 days of the policy renewal date). If no claims have been made we will refund the premium you have paid. If a claim is made we charge you for the days we have been on cover (applying a minimum premium of 15 plus insurance premium tax) and then refund the remainder of the premium you have paid. If you would like to request a policy document, please call us and we will arrange for this to be sent to you. 7 Declaration I declare that to the best of my knowledge and belief all the answers are true and no material fact has been omitted (see important notes above). I agree that if any answer has been written by any other person he/she shall for that purpose be regarded as my agent and not the agent of the Company. I understand that if I elect to pay premiums monthly, the liability of the Company will cease in the event of non-payment of any monthly premium on its due date but that I will always be given 7 days written notice before cancellation takes effect. I/We have read the Important Notes Section and I/we understand how the policy data may be used and have informed other parties related to this insurance accordingly. Your signature(s) Date Day Month Year 7
Premium payment options You may choose between paying an Annual Premium or using our Monthly Payment Plan. You should pay Annual Premiums to your insurance advisor. Please confirm acceptable forms of payment directly with your advisor. Monthly payments are collected from your Bank/ Building Society account by Direct Debit. Monthly Payment Plan Regulated by the Consumer Credit Act 1974 (APR 21.5%) To qualify? You must be at least 18 years old and you must have a Bank/Building Society account that permits Direct Debits to be charged (if in doubt, please check with your Bank/Building Society). How does it work? We will collect the first two monthly premiums from your account by Direct Debit immediately. Thereafter we will collect your premiums at monthly intervals by Direct Debit, commencing two months after the policy is taken out. You will be notified of the amount and date of all collections in writing before your account is debited. The Direct Debit system is carefully regulated by the operating banks to make sure that YOUR interests are always fully safeguarded please see the Direct Debit Guarantee overleaf. What about future premium changes? If you alter your policy at any time your monthly instalment may change; in addition, the premium required for your policy will be reviewed annually. In either circumstance we will write to you in advance informing you of any change to the monthly instalment amount required. How do I cancel my policy? If you wish to cancel your policy simply give us written notification. Please also inform your Bank/Building Society to cancel your Direct Debit Instruction. What happens if Zurich does not receive a Monthly Payment? If your Bank or Building Society does not honour any Direct Debit application, cover under your policy will cease 7 days after the date we have sent written notice to you. It is accordingly very important that you notify us immediately if you change your address or move your bank account. Monthly Payment Plan what it costs To work out the monthly premium all you have to do is take the annual premium, add Insurance Premium Tax at the current rate and then add 9% to it. Divide this figure by twelve to get the monthly premium. For example, if you want to convert an Annual Premium of 347.21 to a Monthly Premium it s simply: 347.21 Premium including IPT at current rate 31.25 add 9% (instalment charge) 378.46 Total annual premium 31.54 12 = total monthly amount payable To apply, please complete the Direct Debit instruction enclosed and return it to your insurance advisor or Zurich at the address shown overleaf on the Direct Debit instruction. 8
Direct Debit instruction Instruction to your Bank or Building Society to pay Direct Debits Please complete parts 1-5 using a ball point pen and send it to: Zurich Insurance, PO Box 458, Cardiff CF10 5WY. 1. Name and full postal address of Bank or Building Society Branch To the Manager Originator s identification number 7 6 3 8 6 4 4. Bank or Building Society account number Reference number Bank or Building Society Address Postcode 2. Name(s) of account holder(s) 5. Instruction to your Bank or Building Society Please pay Zurich Insurance Direct Debits from the account detailed on this Instruction subject to the safeguards assured by The Direct Debit Guarantee. I/we understand that this instruction may remain with Zurich Insurance and if so, details will be passed electronically to my Bank/Building Society. Signatures of Account Holder(s) 3. Branch sort code (from the top right-hand corner of your cheque) Date Banks and Building Societies may not accept Direct Debit Instructions for some types of account. The Illustration below shows the information needed from your cheque to complete the direct debiting instruction Bank or Building Society Address (Please Quote Full Postal Address) XYZ Bank PLC 15 High Street, Anytown AB2 3CD Pay Zurich Insurance 807632 062041 78432681 Name of Account Holder 06-20-41 20 or order JOHN SMITH Cheque Number Sort Code Account Number Sort Code The direct debit guarantee This Guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme. If an error is made in the payment of your Direct Debit, either by us, Zurich Insurance or by your Bank or Building Society, you are entitled to a full and immediate refund from your bank branch. Simply contact your Bank or Building Society to arrange a refund, or if you prefer contact Zurich Insurance and they shall arrange to repay you direct. You can cancel a Direct Debit at any time by writing to your Bank or Building Society. Please also send a copy of the letter to us. If there are any changes to the amount, date or frequency of your Direct Debit, Zurich Insurance will notify you in advance of your account being debited, this will be 7 working days or otherwise agreed. If you request us to collect a payment, confirmation of the amount and date will be given to you at the time of the request. 9
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Zurich Insurance plc A public limited company incorporated in Ireland Registration No. 13460. Registered Office: Zurich House, Ballsbridge Park, Dublin 4, Ireland. UK branch registered in England and Wales Registration No. BR7985. UK Branch Head Office: The Zurich Centre, 3000 Parkway, Whiteley, Fareham, Hampshire PO15 7JZ. PL6/5906.28 (500378028) (03/14) RRD Zurich Insurance plc is authorised by the Central Bank of Ireland and subject to limited regulation by the Financial Conduct Authority. Details about the extent of our regulation by the Financial Conduct Authority are available from us on request. These details can be checked on the FCA s Financial Services Register via their website www.fca.org.uk or by contacting them on 0800 111 6768. Our FCA Firm Reference Number is 203093. Communications may be monitored or recorded to improve our service and for security and regulatory purposes. Copyright Zurich Insurance plc 2014. All rights reserved. Reproduction, adaptation, or translation without prior written permission is prohibited except as allowed under copyright laws. The pulp used in the manufacture of this paper is from renewable timber produced on a fully sustainable basis. The pulp used in the manufacture of this paper is bleached without the use of chlorine gas (ECF Elemental Chlorine Free). The paper is suitable for recycling.