ⓘ Important please read Where to find our reference number example Step 1 of 4 - Start 25% StartOur reference number?*8-digit number, starting with a 2, 3, 4 or 5, found at the top of any letter from Ember JD. Quote start date?* Date Format: DD slash MM slash YYYY Quotes valid for up to 30 daysPolicyholderName?* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First name Surname Email address?* Enter Email Confirm Email Insured address?* Street Address Address Line 2 City Postcode Add Buildings, IF not already includedDo you require a quote to add buildings insurance to your policy?*Not requiredYesREBUILDING cost of the property?*Input your sum insuredAccidental damage cover required for buildings?Not requiredYesBuildings voluntary excess (with a premium discount)?*£100£250£500£1,000£2,500£5,000Zero Add contents, IF not already includedDo you require a quote to add contents insurance to your policy?*Not requiredYesCONTENTS sum insured?*Input a sum insured Accidental damage cover for contents?Not requiredYesContents voluntary excess (with a premium discount)?*£100£250£500£1,000£2,500£5,000ZeroValuables single item(s) over £1,500 within your home?Not requiredYesValuables defined as gold, silver, precious metals or stones, watches, gold and silver plated articles, fur, guns, and firearms, curios, antiques, pictures and other works of art, collections of stamps, coins and medals within your home only.LIST VALUABLES OVER £1,500 WITHIN YOUR HOME*Description of each item or set over £1,500New Value £ Click on ⨁ sign to add extra item(s) Description example: Diamond and platinum ring ✔ Ring ❌DO YOU REQUIRE COVER AWAY FROM HOME?*Not requiredYesJewellery, watches, personal possessions worn or carried about your person, bicycles, personal money and cardsUNSPECIFIED POSSESSIONS AWAY FROM HOME?*Not required£1,500 with single item limit of £750£2,000 with single item limit of £1,000£2,500 with single item limit of £1,250£3,000 with single item limit of £1,500If required select a sum insuredSPECIFIED ITEMS AWAY FROM HOME?*Not requiredYesJewellery, watches, cameras over £1,500. Mobile phones and computers over £750. Hearing aids of any value. LIST SPECIFIED ITEMS OVER £1,500 AWAY FROM HOME*Description of each item or setNew Value £ Click on ⨁ sign to add extra item(s) Description example: Diamond and platinum ring ✔ Ring ❌BICYCLES AWAY FROM HOME?*Not requiredYesLIST BICYCLES AWAY FROM HOME*Make and model of each bicycleNew Value £ Click on ⨁ sign to add extra item(s) Input details in each box, as missing information will mean we cannot quotePERSONAL MONEY & CARDS AWAY FROM HOME?*Not requiredYes (personal money £500 & credit cards £1,000)Error - cannot proceedYou asked for cover away from home, but said not required to the 4 options Security detailsAre all external doors fitted with 5 lever mortice deadlocks or UPVC / aluminium doors fitted with a multi point locking system?*YesNoAre all accessible windows fitted with key locks?*YesNoIs there a professionally installed burglar alarm, with an annual maintenance contract?NoYesIf yes, alarm connected to a monitoring station?NoYesFinal questionsWill the property be unoccupied for a continuous period exceeding 60 consecutive days?*NoYes - cannot quoteWill any trade or business be carried out in your property?*NoYes - clerical use onlyYes - including business visitors to your propertyHas the property ever been damaged by subsidence, heave or landslip, monitored for subsidence, survey reported movement, showing signs of cracking or within an area subject to subsidence?*NoYes (give details in box below)Please give details*For requirements for us to look at offering a quote Click-HereAre there any trees over 5 metres tall within 5 metres of the property?*NoYes (give details below)Provide details of each tree over 5 metres tall within 5 metres of the property*Tree on your land?Species of tree?Approximate height of the tree?Approximate distance from the property? Input details in each box, as missing information will mean we cannot quoteMade any claims under home insurance policy for this or any other property or any incidents of damage or loss not insured, in the last 5 years?*NoYes (give details in box below)Please give details*Month / YearType of Claim / Brief DescriptionCost £ Input details in each box, as missing information will mean we cannot quotePlease go back and input a Buildings and/or Contents sum insuredYou have answered 'not required' to insuring both buildings and contents insurance, so we have nothing to quote on. Please go back and input your sum(s) insured. IMPORTANT INFORMATION WHICH MUST BE READ IN FULLThe information contained in this Statement of Fact forms the basis of your policy and is fundamental to the risk assumed by the Insurers. You must notify Ember JD Insurance Brokers immediately if any of the above details are incorrect as your cover might be invalidated if you do not. Misrepresentation We declare that to the best of my knowledge and belief the information I/We have provided in connection with this proposal to Ember JD Insurance Brokers, whether in my own hand or not, is true and complete and I/We have not withheld or misrepresented any information. I/We ask underwriters to act upon the information provided and issue a contract of insurance between us and I/We agree to accept underwriter’s policy terms, conditions and exclusions. I/We consent to the seeking of information from other insurers to check the answers I/We have provided and I/We authorise the giving of such information for such purposes. I/We understand that if I/We have withheld or misrepresented any of the information contained in this proposal, underwriters may be entitled to void the insurance. Data Protection Act 1998 By accepting this Statement of Fact you consent to Ember JD Insurance Brokers using the information we may hold about you for the purpose of providing insurance and handling claims, if any, and to process sensitive personal data about you where this is necessary (for example, health information or criminal convictions). This may mean we have to give some details to third parties involved in providing insurance cover. These may include insurance carriers, third party claims adjusters, fraud detection and prevention services, reinsurance companies and insurance regulatory authorities. Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use by us as set out above. The information provided will be treated in confidence and in compliance with the Data Protection Act 1998. You have the right to apply for a copy of you information (for which we may charge a small fee) and to have any inaccuracies corrected. Basis of Cover I understand that my acceptance of this Statement of Fact does not bind me to complete the insurance but agree that, should a contract of insurance be concluded, this Statement of Fact and the statements made in it and the information provided in connection with it will be relied upon by the underwriters in deciding whether to accept this insurance. Your records You should keep a record (including copies of any letters) of all information supplied to Ember JD Insurance Brokers for the purpose of entering into this insurance. Change in Circumstance You must inform Ember JD Insurance Brokers of any change in circumstances which may affect this insurance. If you are in any doubt you should consult Ember JD Insurance Brokers. E.U. Disclosure Clause (UK) Notice to the Proposer / Insured: The parties are free to choose the law applicable to this insurance contract. Unless specifically agreed to the contrary this insurance shall be subject to English Law. Complaints Any enquiry or complaint should be addressed in the first instance to your broker, Ember JD Insurance Brokers. The process for complaining directly to Lloyds can be found in the Complaints section of your Policy Wording. The Financial Ombudsman If you are still not satisfied with the way a complaint has been dealt with you may ask The Financial Ombudsman to review your case without prejudice to your rights in law. You can contact The Financial Ombudsman at: The Financial Ombudsman Service Exchange Tower London E14 9SR Telephone: 0800 023 4567 www.financial-ombudsman.org.uk.