ⓘ Important please read Step 1 of 5 - Start 20% StartLet us know your interest in the property?*FreeholderResidents associationManagement companyLeaseholder (cannot quote)Renewal or cover start date?* DD slash MM slash YYYY Quotes valid for up to 30 days Enter details of the insurance proposerIs the property insured in name of freeholder, joint freeholders, residents or management company?*FreeholderJoint freeholdersResidents association or management coFreeholder* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First name Surname Names of the joint freeholders*TitleFirst nameSurname (click plus sign to add joint freeholder(s) Click ⨁ sign to add joint freeholder(s) namesName of residents association or management company* Email address?* Enter email Confirm email Telephone number?* Enter details about the property to be insuredInsured address* Street Address Address Line 2 City Postcode Is the property in a good state of repair and will be maintained as such?YesNo (cannot quote)Overall occupancy of the maisonettes in the property?*Fully occupiedPart occupied / unoccupiedUnoccupied (cannot quote)Choose from the drop down box belowType of occupants?*Freeholder / leaseholder occupiedLet to professional tenantsA mix of freeholder / leaseholder occupied and let to professional tenants flatsPart or all DSS, student or asylum seeker lets (cannot quote)Part or all holiday lets (cannot quote)Choose from the drop down box belowIs the block of maisonettes purpose built or conversion?*Purpose builtConversionApproximate year property built?* Approximate year property purchased?* Is the property listed?*NoYesConstruction of the external walls?*BrickStone / flintConcreteTimber frame with brick wallsTimber frame with plaster panelsTimber frame with cedar claddingTimberWattle and daubCobPrefabricated (cannot quote)Type to use search 🔍 Construction of the roof?*Tile or slateZincRubber (EPDM)Single ply membraneFelt over timberConcrete slabThatch (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%100% flat roofTotal number of maisonettes in the building / block?*We only insure all of the maisonettes in the building / blockTotal number of storeys, including any basements?*Construction of the floor?*TimberConcrete Enter details about the buildings cover requiredℹRebuilding cost of the property?* The sum insured should include all of the maisonettes in the block For a quote for single maisonette click hereRebuilding cost of the property?* The sum insured should include all of the maisonettes in the block For a quote for single maisonette click hereAccidental damage cover required for buildings?Not requiredYesVoluntary excess with premium discount?*£100£250£500£1,000£2,500£5,000Zero Has the proposer(s) and the property to be insuredAny 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* 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* Is 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 visible signs of cracking or within an area subject to subsidence?NoYes (cannot quote)Are there any trees or shrubs over 5 metres tall within 5 metres of the property?NoYes (cannot quote)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*Month / YearType of Claim / Brief DescriptionCost £ Ensure you have input details in each box, as missing information will mean we cannot quoteHiddenIMPORTANT 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.