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 - Insurance proposer 25% Enter details about the insurance proposerRenewal or cover start date?* DD slash MM slash YYYY Quotes valid for up to 30 daysIs the property insured in name of a sole freeholder, joint freeholders, residents, management or RTM company?*Sole freeholderJoint freeholdersResidents association, management or RTM companySelect from the following: Sole freeholder Joint freeholders Residents association Management company Right to Manage (RTM) company Sole freeholder* Select from drop-downMr.Mrs.MissMs.Dr.Prof.Rev. Title First name Surname Names of joint freeholders*TitleFirst name in fullSurname (click plus sign to add more freeholder(s) Add Remove Add RemoveCLICK ⨁ BUTTON TO ADD MORE JOINT FREEHOLDER(S) NAMESFull name of the residents association, management or RTM company?*Do you recharge the cost of the buildings insurance to the leaseholders / tenants?*Excluding anyone named as a policyholderℹNoYesDo you recharge the cost of the buildings insurance to the leaseholders / tenants?*Excluding anyone named as a policyholderℹNoYesEmail 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 insured and the occupancyAddress 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 complete first line of the property address, add it here, otherwise if correct, leave blankTotal number of flats in the building / block?*We only insure all of the flats in the building / blockOverall occupancy of all the flats in the property?*Fully occupiedPart occupied / unoccupiedUnoccupied (cannot quote)Choose from the drop down box belowNumber of flats that are unoccupied?*Please enter a number from 1 to 50.Type of occupants?*Freeholder / leaseholder occupiedLet to professional tenantsA mix of freeholder / leaseholder occupied and let to professional tenants flatsPart or all let to DSS claimants, students or asylum seekers (cannot quote)Part or all holiday lets (cannot quote)Choose from the drop down box belowType of occupants?*Freeholder / leaseholder occupiedLet to professional tenantsPart or all let to DSS claimants, students or asylum seekers (cannot quote)Part or all holiday lets (cannot quote)Choose from the drop down box belowIs the block of flats purpose built or conversion?*Purpose builtConversionApproximate year property first built?*Approximate year property purchased?*Construction of the external walls?*BrickStoneConcreteFlintTimber frame with brick wallsSteel frame with brick or concrete wallsType to use search 🔍 Construction of the roof?*Tile or slateZincConcrete slabRubber (EPDM)Single ply membraneFelt over timberAsphaltThatch (cannot quote)Type to use search 🔍 Approximate percentage of any flat roof?*0%Up to 10%Up to 20%Up to 30%Up to 40%Up to 50%Up to 75%100% flat roofConstruction of the floor?*TimberConcreteTotal number of storeys, including any basements and lofts converted to flats?* 2 3 4 Maximum number of four storiesIs the property listed?NoYes Enter details about the buildings cover requiredℹRebuilding cost of the property £?*The sum insured should include all of the flats in the blockAccidental damage cover required for buildings?*Not requiredYesVoluntary excess with premium discount?*£100£250£500£1,000Zero About the property to be insured and the proposer(s)Is the property in a good state of repair and to your knowledge, free from damage or defect and will you continue to maintain it properly in the future?*YesNo (cannot quote)Do you plan on carrying out any renovations, conversions, extensions or other structural alterations to the property in the next 12 months?NoYesIs the property within 400 metres of any riverbank, sea front, lake, reservoir or quarry?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 (cannot quote)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*Are there any trees or shrubs over 5 metres tall within 5 metres of the property?*NoYesDetails of each tree over 5 metres tall within 5 metres of the property?*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)Tree on your land (yes or no)?Species of the tree?Approximate height of the tree?Approximate distance away from the property? Add RemoveAny unspent criminal conviction(s) or been charged (but not yet tried)?*NoYes (give details in box below)Please give details*Ever been declared bankrupt, insolvent or the subject of bankruptcy, insolvency or a County Court Judgement?*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*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. The Consumer Insurance (Disclosure and Representations) Act 2012 sets out situations where failure by a policyholder to provide complete and accurate information requested by an insurer allows the insurer to cancel the policy, sometimes back to its start date and to keep any premiums paid. The Act also places a duty on the Insurer to ensure that the questions they ask the policyholder are clear, specific and not misleading. 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.