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. Step 1 of 4 - About You 25% Enter details about the insurance proposerRenewal or cover start date?* DD slash MM slash YYYY Quotes valid for up to 30 daysWill the policy be in the name of an individual or company?*Individual's nameCompany nameFull name?* Select from dropdownMr.Mrs.MissMs.Dr.Prof.Rev. Title First name Surname Company name?*Input full company nameEmail 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 Enter details about the property to be insuredAddress of property to be insured?*Enter postcode, then select address from drop-down England, Wales & mainland Scotland addresses only Postcode 1st line 2nd line Town / city Postcode If you cannot select the full first line from the address lookup, add it hereDo you owner occupy the property?*NoYes (cannot quote)Overall occupancy of the property?*100% occupiedPart occupied, part unoccupied100% unoccupiedWill the property be unoccupied for a continuous period exceeding 30 consecutive days during the insurance period?*NoYes (give details in box below)Please give details*Property to be insured occupied as?*FlatsOfficeOffice with flats aboveShopShop with flats aboveSurgerySurgery with flats aboveWarehouseIndustrial unitFarm building for storageFarm building for livestockType to use search 🔍 Total number of flats?*Trade or profession of your business tenant(s)?* Add RemoveIf more than one business tenant, click on ⨁ sign to add more rows Is the property in a good state of repair and will be maintained as such?YesNo (cannot quote)Approximate year property built?*Approximate year property purchased?*Construction of the external walls?*BrickStone / flintConcreteSteel frame with brick wallsSteel frame with concrete wallsTimber frame with brick wallsTimber frame with plaster panelsTimber frame with cedar claddingTimberPrefabricated (cannot quote)Type to use search 🔍 Construction of the roof?*Tile or slateZincConcrete slabRubber (EPDM)Single ply membraneFelt over timberAsphaltThatch (cannot quote)Approximate percentage of any flat roof?*0%Up to 5%Up to 10%Up to 20%Up to 30%Up to 40%Up to 50%100%Total number of storeys including any basements?* 1 2 3 4 5 Floor construction?*TimberConcreteType of heating?*Radiators (hot water)Radiators (oil)Night storage heatersWarm airUnderfloorPortable heatersWood burnerStoveNo heatingType of residential tenant?*No residential tenantsLeaseholderPrivate rentalLeasehold and private rentalPart or all holiday lets (cannot quote)Students (cannot quote)DSS claimants (cannot quote)Asylum seekers (cannot quote)Type to use search 🔍 Enter details about the buildings cover requiredRebuilding cost of the property £?*Your assessment of the cost of current full reinstatement of the property including materials, labour, compliance with any public authority requirements, professional fees and removal of debris. Accidental damage cover required for buildings?*Not requiredYesSubsidence cover required for buildings?*Not requiredYesTerrorism cover required for buildings?*Not requiredYesLoss of rent sum insured?*Please enter a number greater than or equal to 5000.(following insured damage) Loss of rent indemnity period?*12 months24 months36 months(following insured damage)Do you require employer's liability?*YesNoAnnual payments?*Such as window cleaners, gardeners, maintenance, and cleaners Has the proposer(s) and the property to be insuredAny unspent criminal conviction(s), been charged (but not yet tried) or Court Court Judgement(s)?*NoYes (give details in box below)Please give details*Ever been declared bankrupt, subject of bankruptcy proceedings or insolvency?*NoYes (give details in box below)Please give details*Ever had a proposal declined, had a policy cancelled by an insurer, renewal refused or had special terms imposed?*NoYes (give details in box below)Please give details*Do you plan on carrying out any renovations, conversions, extensions or other structural alterations to the property in the next 12 months?*NoYes (give details in box below)Please give details*Has the property or the neighbouring area ever flooded or in an area at risk of flooding?*NoYes (give details in box below)Please give details*Has the property ever been damaged by subsidence, ground heave or landslip, monitored for subsidence, survey reported settlement or movement, showing signs of cracking or within an area subject to subsidence?*NoYes (give details in box below)Please give details*Made any claims under property 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*If you do not have all the information you can save and return later, as incomplete answers will mean we cannot quote Click ⨁ to add more row(s)Month / YearType of Claim / Brief DescriptionCost £ Add RemoveThis field is hidden when viewing the formIMPORTANT 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 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.