Application for cover on behalf of client

Step 1

Name and address of broker (if used)

Telephone number

Email contact

Agency number (if known)

Name of property owner *

Occupation of property owner *

Has any person owning or living at the property to be insured ever been convicted of a criminal offence? No Yes

If Yes, please give details

Name of contractor to be noted as Joint Insured (if applicable)

Contact name and address for the enquiry (please repeat here if already stated) *

Contact telephone number (please repeat here if already stated) *

Contact email for this enquiry (please repeat here if already stated) *

Name and address of any Mortgagee whose interest is to be noted in this insurance

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Step 2

Address of property to be insured *

Postcode of property to be insured *

Approximate age of property *

Rebuild value of property (Sum Insured) *

Condition of property * Excellent Good Fair Poor

Type of property * Detached Semi-detached Terraced Flat

Are the walls and roof of standard construction throughout (being brick, stone or concrete walls with slate, tile, concrete, metal or asphalt roof) No Yes

If No, then please give details of construction (eg. thatch roof, timber frame, etc) *

Is the property listed? No Yes

If Yes, then please give details Grade I Grade II

Describe the location of the site/home, eg. remote, estate, etc.

Is the property in an area prone to flooding or in the vicinity of any rivers, streams or tidal waters, or is there any history of flooding at the property? No Yes

Have the premises ever suffered from flooding, whether insured or not? If Yes, then please give details

Have there been any claims at the property that you are aware of in the last 3 years? No Yes

If Yes, then please give details (date, cirumstances, amount of claim(s))

Please give details of physical security on external doors and accessible windows (eg. five lever mortice deadlocks, key operated window locks, etc) *

Please give details of any alarm at the property

Will the property be occupied during works? No Yes

If No, where is the nearest occupied house in relation to the insured property?

How often is it intended that you or a person acting on your behalf (not the contractor) visit the site?

Are the contents to remain in the house? No Yes

When the works are complete, what is your intention for the property? *

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Step 3

Period of contract (if not yet known, give approximate dates) *

Start date:

End date:

Are there any contract conditions in place between the property owner and contractor? (eg. JCT Minor works 6.3B?) No Yes

If Yes, please give details

Give details of work to be undertaken (if there is going to be any structural work, underpinning, piling, demolition or work involving the application of heat you MUST advise us here) *

Will the work involve a depth of excavation exceeding 5metres and/or work in or adjacent to water? No Yes

If Yes, please give details

What is the contract value (including irrecoverable VAT)? *

Will any materials be salvaged? No Yes

If Yes, please give details of what these will be, together with value and how salvaged items will be stored

Details

Value

Do you require cover for temporary buildings? (eg. portacabin, caravan) No Yes

If Yes, please give details of type and value

Type

Value

Do you require cover for items of Plant or Equipment? No Yes

If Yes, please give

a) Total value of Plant or Equipment used during whole contract (£)

b) Highest limit for any one item of Plant or Equipment (£)

Do you require cover for Hired in Property? No Yes

If Yes, please give details of highest limit of any one item of Hired in Property

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Step 4

This proposal and the information provided in connection with it contain statements upon which Underwriters will rely in deciding to accept and in rating this insurance. Should a contract of insurance be concluded this proposal will form the basis of the insurance.

By sending the information in this form to us, you are declaring that to the best of your knowledge and belief the information provided, whether completed by you or on your behalf, is true and that you have not withheld any material facts. You accept and understand that non-disclosure or misrepresentation of any material fact may entitle Underwriters to void any insurance effected. A material fact is one likely to influence acceptance or assessment of this proposal by Underwriters: if you are in any doubt whether a fact is material or not, you must disclose it in the space below.

Data Protection Act 1998 - Proposer's Consent Clause

By submission of this application, you are consenting to any information you may have given us about you being processed by us for the purposes of providing insurance and claims handling, which may require providing such information to third parties.

Please tick box to confirm that you have read, understood and can comply with the terms in this declaration

Somerville group companies accept no responsibility for damage to computer hardware or software caused by the use of this application.

If you have any specific queries that are not catered for by the above questions or answers, you can detail them in the box below

Click here to see a printer friendly version of your responses to the questions. Use the browser back button to return to this page and submit your request, or use the Back button to return and change your answers.

Is there any information you feel we should know about this request for insurence? If so, please give details.