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
Name
(please give details of all other people permanently resident at the above address to which
this insurance is to apply [ignore children under 16])
Age
Continue on a separate sheet if necessary
Relationship to proposer
Occupation or precise nature of business
THE PREMISES
Year premises built:
YES
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
f
g
h
i
j
k
l
m
n
Are the premises free from flooding, in an area free from flooding and not in the vicinity
of any rivers, streams or tidal waters?
Are the premises regularly left unattended by day or night (excluding normal working
hours)?
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?
Is or has the home or its domestic outbuildings ever been monitored for subsidence,
landslip or heave?
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)
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)
Is the home, or its domestic outbuildings, heated by oil fired central heating?
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?
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?
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
NO
SECURITY OF THE HOME
It is important to give as full a description as possible.
a
b
c
d
Types of locks on all external doors (eg
five lever mortise deadlocks) excluding
communal doors in flats
Types of locks on patio doors and French
windows, fan lights and skylights (eg key
operated bolts)
Types of window locks or catches (eg,
screw or key operated)
Details of intruder alarms
i
ii
iii
e
f
Installer make and model
Is it maintained under contract by the
installing company?
Signalling (eg bells only, digital
communicator, ABE, Packnet,
Redcare or central station)
YES/NO
Details of safe
i
Type (eg wall, under floor,
freestanding)
ii
Make and model of safe
Iii
Was our safe professionally installed:
YES/NO
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
ii
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
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:
b
Amount of each loss or
damage
a
Date 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)
If Yes please give details:
YES/NO
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 www.fscs.org.uk)
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.