Private Clients Household Proposal Form

PRIVATE CLIENTS HOUSEHOLD PROPOSAL FORM

PROPOSER

Title:
Forenames:
Surname:
Address:
Postcode:
Date of Birth: / DD/MM/YYYY
Are you a resident of the United Kingdom:
Occupation and
precise nature of
business
Note: Indicate precise nature of business (including details of any form of professional entertaining):
It is not sufficient to state “secretary”, “salesman”, “company director”. Include any part-time or casual jobs.
Address of premises to
which this insurance is to
Apply (if different from above)
Postcode:
Home phone number:
Daytime phone number:

OTHER PERSONS(please give details of all other people permanently resident at the above address to which this insurance is to apply [ignore children under 16])

Name / Age / Relationship to proposer / Occupation or precise nature of business

Continue on a separate sheet if necessary

THE PREMISES

Year premises built:
YES / NO
a / Are the premises occupied as your permanent residence?
b / Are the premises used in any part for a business, trade or profession?
c / Is the home, at the premises, built of brick, stone or concrete and roofed with slate, tiles or concrete?
d / Are the premises, the home, and its domestic outbuildings, in a good state of repair?
e / Are the premises free from flooding, in an area free from flooding and not in the vicinity of any rivers, streams or tidal waters?
f / Are the premises regularly left unattended by day or night (excluding normal working hours)?
g / Is the home and its domestic outbuildings free from signs of damage due to subsidence, landslip or heave (such as internal or external cracks) and not in an area where there has been a history of these causes?
h / Is or has the home or its domestic outbuildings ever been monitored for subsidence, landslip or heave?
i / Is or has the home or its domestic outbuildings ever been subject to a survey which mentions settlement or movement of buildings? (If yes, please enclose a copy of this document)
j / Are there any trees or shrubs within 20 feet of the home or its domestic outbuildings(whether inside or outside your garden) which are more than 10 feet tall? (If yes, please state height, distance form and species in the box below)
k / Is the home, or its domestic outbuildings, heated by oil fired central heating?
l / Are you able to confirm that you do all you reasonably can to put into operation the security at the premises to be insured, including alarm(s) if you have them/one, when the premises are left unattended?
m / If you have a safe are you able to confirm that you do all you reasonably can to use it, for the storage of your jewellery, whilst your jewellery is not being worn, in your custody and control or in a similar safe (including that of a bank, hotel, restorer etc) whilst temporarily removed from the home?
n / If the resident is a flat:
i / Is it self contained having its own lockable entrance under your sole control?
ii / On which floor is it
If you have ticked any of the shaded boxes, please give full details below.
Question / Details

Continue on a separate sheet if necessary

SECURITY OF THE HOME

It is important to give as full a description as possible.

a / Types of locks on all external doors (eg five lever mortise deadlocks) excluding communal doors in flats
b / Types of locks on patio doors and French windows, fan lights and skylights (eg key operated bolts)
c / Types of window locks or catches (eg, screw or key operated)
d / Details of intruder alarms
i / Installer make and model
ii / Is it maintained under contract by the installing company? / YES/NO
iii / Signalling (eg bells only, digital communicator, ABE, Packnet, Redcare or central station)
e / Details of safe
i / Type (eg wall, under floor, freestanding)
ii / Make and model of safe
Iii / Was our safe professionally installed: / YES/NO
f / Any other security precautions (eg fire extinguishers or alarms, security lighting etc?)

STATEMENT OF VALUES TO BE INSURED

a / Buildings(full cost of reconstruction in their present form to include debris removal and professional fees)
Cover under the Buildings section is for loss or damage and includes all garages and outbuildings used for domestic purposes together with any permanently installed lighting, swimming pools, tennis courts, driveways, footpaths, patios and terraces, walls, gates, fences, hedges, fixed fuel tanks, permanently installed hot tubs and wind turbines within the premises to be insured.
Sum Insured
£
Where buildings insurance is required, state roll number and name and address of any building society or other financial institution that you require to be named under the Buildings Section as co-insured
b / Contents (full cost of replacement as new)
Cover under the Contents section is for loss or damage including worldwide cover for items whilst temporarily away from the home, including clothing, baggage and other personal possessions, up to the contents sum insured.
The following categories are also automatically included under contents subject to the limits shown: Jewellery and furs – Limit £5,000, Gold and Silver – Limit £5,000, Stamps and Coins – Limit £5,000, Personal Money – Limit £2,500, Credit Cards – Limit £25,000. The limits shown are the totals for each category.
Sum Insured
£
c / Valuables, antiques and works of art, gold and silver
Sums insured are in addition to the contents sums insured.
i / Total value of Antiques, Works of Art and any collections ie, coins, stamps and medals within your home (current market value) / £
Individual items worth more than £15,000 must be specified below:
Antiques and Works of Art include furniture, paintings, drawings, china,
sculptures, glass and porcelain
ii / Total value of Gold and Silver within the home(current market value) / £
Individual items worth more than £5,000 must be specified below.
iii / Total value of Jewellery and Furs (current market value) / £
Individual items worth more than £5,000 must be specified below
Please note that it will be necessary to provide descriptions and values for items where the value is in excess of £5,000 under categories c) ii) and c) iii) and £15,000 under c) i) of this proposal.

Items to be Specified:

1 / £
2 / £
3 / £
4 / £
5 / £
6 / £
7 / £
8 / £
9 / £
10 / £
11 / £
12 / £

Continue on a separate sheet if necessary

COMMENCEMENT DATE

From which date do you require this insured to start?

PREVIOUS INSURERS

a / Name of previous insurers
b / Date of expiry of policy
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 would apply? / YES/NO
If Yes please give details:

PREVIOUS CLAIMS

Has the proposer, or any other person whose property is to be insured under this policy suffered any loss or damage during the last six years which would have been covered by this type of insurance had it been in force, whether or not a claim was paid? / YES/NO
If yes please state:
a / Date of each loss or damage / b / Amount of each loss or damage
c / Details of each loss or damage
d / If any previous losses involved theft from the current premises, please explain:
i. how entry was gained: and
ii. what subsequent precautions have been undertaken to prevent a similar occurrence?

Continue on a separate sheet if necessary

CRIMINAL CONVICTIONS

Have you, or any person residing with you, ever been convicted of, or charged with but not yet tried for, any offence other than a driving offence? (subject to the Rehabilitation of Offenders Act 1974) / YES/NO
If Yes please give details:

DATA PROTECTION ACT 1998

We will handle any information you have given, in line with the conditions of the Data Protection Act 1998. To provide insurance and handle claims we may need to provide this information to other people.

FOR YOUR PEACE OF MIND

The Insurance Provider is covered by the Financial Services Compensation Scheme. You may be entitled to compensation from the scheme if they cannot meet their obligations to you under this contract. If you are entitled to compensation under the scheme, how much compensation you would receive would depend on the nature of this contract. You can get more information about the scheme from the Financial Services Compensation Scheme (7th Floor, Lloyds Chambers, Portsoken Street, London, E1 8BN and on their website

DECLARATION

To the best of my knowledge and belief the information provided in connection with this proposal, whether in my own hand or not, is true and I have not withheld any material facts. I understand that non-disclosure or misrepresentation of a material fact may entitle Underwriters to void the insurance (N.B. A material fact is one likely to influence acceptance or assessment of this proposal by Underwriters: if you are in any doubt as to whether a fact is material or not you must disclose it in the space below)
This proposal and the information provided in connection therewith contain statements upon which the Underwriters will rely in deciding to accept this insurance. Should a contract of insurance be concluded this proposal will form the basis of the insurance.

SIGNATURE OF PROPOSER(S)DATE

Please note: If you have provided any information on a separate sheet please ensure that it is signed, dated and returned with this proposal form.