All material facts known to you must be disclosed. A material fact is one which is likely to, influence an insurer in the assessment and acceptance of the proposal. Should you have any doubt as to whether a fact is material it should be disclosed for your own protection as failure to disclose such facts will invalidate the policy.

1. Proposer's name in full Mr./Mrs./Miss. (Joint names where applicable)            

2. Address of property to be insured                                                                                          3. Correspondance address if different

4. Occupation of insured              of Spouse    

Telephone                    Mobile  :               Time at present address    

5. Name of present/past insurer                           Policy number & expiary date     

Date insurance to commence                  (dd-mm-yyyy)          Year property built      

6. Occupancy

Is the property ?                Please Select A House A Flat A Bungalow Detached Semi-Detached Terraced Others           If Others then describe here     

OR    Please Select Owner/Occupied Unoccupied To be Let to a Professional Student DSS Tenant Asylum Seeker Others          If Others then describe here     

No. of Rooms                 No. of Tenants          

7. Security for un-occupied property arrangements

Please confirm the following

a) All external doors are fitted with 5 lever mortice deadlocks or similar security locks, or fastenings and all opening windows are fitted with window locks or

double glazing.     Please Select Yes No           If No, describe arrangements in detail here      

b) The supply of gas and electricity to the premises has been disconnected     Please Select Yes No

c) The premises are inspected every 7 days by the owner or his representative and a signed/dated log is kept.     Please Select Yes No

d) Are there any other security features ( such as alarms ) ?     Please Select Yes No            If Yes, describe in detail here      

e) Approximately how far to the nearest fire station ?       Miles -                Police Station      Miles

f) If NO answered to any questions, then please explain arragements in here           

g) Adjacent Property

i) Is adjacent property occupied ?       Please Select Fully In Part No

ii) If adjacent property occupied for what occupations ( state if residential )         

h) i) Please indicate the reason why the premises are vacant ?                             

ii) How long has premises been unoccupied prior to this application ?                   

i) Are the premises ?     Please Select For Sale To Let To be Redeveloped Others           If Others then describe here     

SECTION                                                                                                                                                                                                        Sum Insured

1. BUILDING : - The sum insured should represent the estimated rebuilding cost of the private dwelling house and garages and domestic outbuildings within the curtilage thereof and used in conjunction therewith.                                                                                                                                                   £  

If let, please advise the loss of rent if required - 12 months                                                                                                                            £  

2. CONTENTS : - The sum should be the total value of all the contents of your home including internal decorations. ( if you are a tenant ), personal possessions, furniture, furnishings and household goods and all effects, all belongings for which you are legally responsible and which are in private use but Excluding antiques, jewellery, articles of gold, silver or other precious metals, watches, furs, money, caravans, documents as these excluded items are not covered by this certificate.                                                                                                                                                                                                £  

Do the contents belong to - Please Select You as the owner As the Landlord

NB : - The policy excludes the first £100 of each and every incident of loss or damage ( apart from let property, which is to be agreed ). Subsidence, heave and/or

Landslip, including ( malicious damage caused by guests or tenants ) £2500.

Please provide details of Bank/Building Society if building is subject to a mortgage.

Name of Lender

THE FOLLOWING MUST BE ANSWERED :

I/We declare that :

a. The sums insured under Sections 1 & 2 represent full value on the basis for which insurance is requested

and during the currency of the Policy will remain so.    Please Select Yes No

b. The building is in an area normally free from flooding, subsidence and landslip and is without evidence of

previous damage from these contingencies.     Please Select Yes No

c. The building is built of brick stone or concrete and roofed with slates, tiles, asphalt metal or concrete and in good repair.     Please Select Yes No

d. The whole of the building is : -

i) Regularly attented during the day and night.     Please Select Yes No

ii) Occupied solely by me and my family for private residential purpose.    Please Select Yes No

e. My home is self - contained and has its own external lockable entrance door ( s ).     Please Select Yes No

f. My home is fully furnished solely by me and my family.    Please Select Yes No

g. I and my spouse and members of my family permanently residing with me have been free of any declaration of bankruptcy or convictions or arson, fraud,

forgery, theft, robbery or receiving or any crime of violence associated with any of those offences or with any other offences against property.     Please Select Yes No

Insert here further details where the answer is 'No'.

In respect of the risks to be insured or have been insured previously with crownsway or elsewhere, have you or any member of your family permanently residing with

you :

i. Sustained any loss, damage or liability over the last 5 years ?     Please Select Yes No

ii. Ever had a proposal form declined, renewal refused, cover cancelled, increase premium required or special terms imposed by any insurer ?     Please Select Yes No

Insert here further details where the answer is 'Yes'.

1. Front and rear exit doors fitted with British Standard 5 leber Mortice deadlocks     Please Select Yes No

2. Accessible windows fitted with window locks.     Please Select Yes No

3. Fitted with a Burglar Alarm.     Please Select Yes No

4. If YES to (3), is it subject to a maintenance contract ?     Please Select Yes No

5. Are you member of a Neighbourhood Watch Scheme ?     Please Select Yes No

6. Are you 50 years of age or above ?     Please Select Yes No

Full Value Condition

It is a condition of the insurance that you maintain sums insured at levels which represent the full value of the property insured.

Full Value Means :

Building : - The estimated rebuilding cost less an allowance for depreciation.

Contents : - The current cost as new less an appropriate allowances for depreciation and wear and tear.

LOSS SETTLEMENTS

BUILDINGS

Deduction is made under CIB Home Insurance Cover for wear and tear, repair and depreciation or betttlement resulting from repairs.

HOME CONTENTS : - Deduction is made under CIB Home Insurance Cover for wear and tear.

LEGAL LIABILITY INSURANCE

( including, without limit, associated legal costs fees and expenses incurred with the insurers written consent ).

Under a Home Contents Policy : - You are covered up to a limit of £1 million against legal liability for injury to others or damage to their property arising from

the occupation of your home or caused in everyday private life anywhere in Europe by you or any member of your family normally residing with you.

Under a Building Policy : -

You are covered as owner up to £1 million against legal liability for accidents as owner of the building apart from unoccupied property unless the cover is

arranged separately.

A copy of the usual form of Policy is available for inspection on request.

I/We understand that there is no jewellery cover under this Policy

DECLARATION

I/We declare that the best of my/our belief the sums to be insured represent the full rebuilding/replacement cost.    

I/We agree that :

(a)The Sums insured under Sections 1 and 2 may be adjusted according to the indices mentioned on the policy.

(b)This proposal form has, to the best of my/our knowledge, been completed correctly.

(c)To the best of my/our knowledge and belief nothing material affecting any of the risks proposed has been concealed.

(d)This proposal shall be the basis of and shall form part of the Contract between myself/ourselves and Crownsway Insurance Broker Ltd.

(e)I/We will pay the premium on demand.

CLAIMS : - It is a condition of this certificate that all the claims should be notified in writing to Crownsway Insurance Broker Ltd. within 14

days of the circumtances giving rise to the claim. Failure to do so will absolve the Company of liability.

[   Agree     ]                    Date : -     (dd-mm-yyyy)

(Cover does not commence until acceptance of the proposal by Crownsway)