Office Unoccupied Quote Form

Step 1 of 4 - Insurance proposer

Insurance proposer(s)
Cover start date?*
DD slash MM slash YYYY
Select an insurance period?*
Enter details of the insurance proposer(s)
Name(s)?*
Title First name Surname
Do you, or any of the proposer(s), reside in the United Kingdom or European Economic Area?*

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Enter details about the property to be insured
Insured address?*
Street address Address line 2 Address line 3 Postcode
Reason for unoccupancy?*
Select from drop down list below
Any works, refurbishment or renovations planned during the policy period that exceed £50,000 when undertaken by an independent contractor or £10,000 when undertaken by anyone other than an independent contractor?*
Number of years unoccupied?*
Approximate year property built?*
Number of bedrooms?*
Type of property?*
Total number of flats in the building?*
Do you have to insure the buildings your flat or maisonette under the terms of your lease?*
Is the property in a condition in which it could be lived in as a home?*
Construction of the external walls?*
Main construction of the roof?*
Percentage of any flat roof?*
Is the property a listed building?*

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Buildings insurance
REBUILDING cost of the property £?*

Input your sum insured
Contents required?*
Contents sum insured?*
Please enter a number greater than or equal to 1000.
Voluntary excess (with premium discount)?*
In addition to the compulsory excesses

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About proposer(s) and the property to be insured
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 a proposal declined, had a policy cancelled by an insurer, renewal refused or had any special terms imposed?
Please give details*
Has the property previously flooded or are you aware of a risk of flooding in the locality?
Please give details*
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?
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 details in each box, as incomplete or missing information will mean we cannot quote
Hidden
IMPORTANT INFORMATION THAT 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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Title	First name	Surname

Month / Year	Type of Claim / Brief Description	Cost £

Step 1 of 4 - Insurance proposer

Insurance proposer(s)

Enter details of the insurance proposer(s)

Enter details about the property to be insured

Buildings insurance

About proposer(s) and the property to be insured