Additional or Replacement Insured Declaration

Please answer the questions carefully and to the best of your knowledge, as our quotation will be based on the details you provide. Incorrect information could lead to an increased premium, claim being declined or invalidate an insurance.

Where to find our reference number: example

Add or replace a policyholder(s) under a current policy
Our reference number?*

8-digit number, found on emails and at the top of any letter from Ember JD.
Date of proposed change?*
DD slash MM slash YYYY
Occupancy of your flat or house as the insured property?*
Select from the drop down box (any other occupancy please contact us)
Enter the address of the insured property?*
Street Address Address Line 2 City Postcode
Are you proposing to be an additional policyholder(s) or replacing a current policyholder(s)?*
Name(s) of current policyholder(s) you propose to replace?*
First name Surname

CLICK ⨁ BUTTON FOR ANY MORE CURRENT POLICYHOLDER(S) TO BE REPLACED
Enter your details as an additional / replacement insurance policyholder
Name?*
Title First name Surname
Date of Birth?*
Occupation?*
Type to use search 🔍
Email address?*
Enter Email Confirm Email
Telephone number?*
Please enter a valid phone number in UK format, starting 07, 01, 02 or +44, with no spaces
Apart from you, is there another additional or replacement Insurance policyholder?
Name?*
Title First name Surname
Date of Birth?*
Occupation?*
Type to use search 🔍
Questions applying to all proposed additional or replacement policyholder(s)
Any unspent criminal conviction(s) or been charged but not yet tried?*
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 £

Input answers in each box, as incomplete or missing information will mean we cannot quote
Hidden
IMPORTANT INFORMATION WHICH MUST BE READ IN FULL
The 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.

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A policy change will be subject to the £15.00 administration fee, which you can pay once you submit this form.

First name	Surname

Month / Year	Type of Claim / Brief Description	Cost £

Add or replace a policyholder(s) under a current policy

Enter your details as an additional / replacement insurance policyholder

Questions applying to all proposed additional or replacement policyholder(s)