Additional or Replacement Insured Declaration

ⓘ Important please read
Where to find our reference number example

Our reference number?*
8-digit number, starting with a 2, 3 or 4, found at the top of any letter from Ember JD
Date of prospective change?*
Date Format: DD slash MM slash YYYY
Enter the address of the insured property?*
Street Address Address Line 2 City Postcode
Are you proposing to be an additional insured or replacing a current insured?*
Name of insured you are replacing?*
First Last
Occupancy of your flat or house at the insured property?*
Select from the drop down box (any other occupancy please contact us)
Enter your details as an insurance proposer
Name?*
Title First name Surname
Date of Birth?*
Occupation?*
Type to use search 🔍
Email address?*
Enter Email Confirm Email
Telephone number?*
Joint proposer?
Name?*
Title First name Surname
Date of Birth?*
Occupation?*
Type to use search 🔍
Any unspent criminal conviction(s) or prosecution(s) pending?*
Please give details*
Ever been declared bankrupt, have any CCJs, IVAs or arrangements with creditors?*
Please give details*
Ever had an insurance proposal declined, had a policy cancelled by an insurer, renewal refused or had special terms imposed?*
Please give details*
Made 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?*
Please give details*
Month / Year Type of Claim / Brief Description Cost £

Ensure you have input details in each box, as missing information will mean we cannot quote

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We will contact you when received. A policy change will be subject to the £15.00 administration fee, which you can pay once you submit the declaration.

Month / Year	Type of Claim / Brief Description	Cost £

Additional or Replacement Insured Declaration

Enter your details as an insurance proposer