ⓘ Important please read Step 1 of 4 - Start 25% StartCover start date?* DD slash MM slash YYYY Quotes valid for up to 30 daysSelect an insurance period?*3 months6 months9 monthsEnter details of the insurance proposer* Mr.Mrs.Miss.Ms.Executors of the lateDr.Prof.Rev. Title First name Surname Joint proposer(s)?NoYesEnter details of the joint insurance proposer(s)*TitleFirst nameSurname Click ⨁ sign to add more joint proposer(s)Do you, or if applicable at least one joint proposer, reside in the United Kingdom or European Economic Area?*I/we reside in the United Kingdom (UK)I/we reside in the European Economic Area (EEA)I/we reside outside of the UK and EEA (cannot quote)Email address?* Enter email Confirm email Telephone number?* Enter details about the property to be insuredInsured address?* Street Address Address Line 2 City Postcode England, Scotland and Wales addresses onlyReason for unoccupancy?*Up for saleOwner moved into a care homeLiving with a family memberOwner deceasedInbetween letsRenovation / refurbishmentHoliday (cannot quote)Damage from fire or flood (cannot quote)Select from drop down list belowAny 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?*NoYes (cannot quote)Number of years unoccupied?*Under a year1 year2 years3 years4 years5 years6 years and over (cannot quote)Please advise us of the reason for the long length of time unccupancy?*Approximate year property built?* Number of bedrooms?*Type of property?*Detached houseDetached bungalowSemi detached houseSemi detached bungalowEnd terrace houseMid terrace houseEnd terrace bungalowMid terrace bungalowIndividual flatIndividual maisonetteDo you have to insure the buildings your flat or maisonette under the terms of your lease?*YesNo (cannot quote)Is the property in a condition in which it could be lived in as a home?*YesNo (cannot quote)Construction of the external walls?*BrickStoneConcreteTimber framed with brick wallsTimber framed with cedar claddingPrefabricated (cannot quote)Main construction of the roof?*Tile or slateZincRubber (EPDM)Single ply membraneFelt over timberFibre cement sheetingThatch (cannot quote)Approximate percentage of any flat roof?*No flat roofUp to 20%Up to 30%Up to 40%Up to 50%Up to 100%Is the property a listed building?*NoYes Buildings insuranceREBUILDING cost of the property £?* Input your sum insured Contents sum insured?Not required£3,000£5,000£7,500£10,000£12,500£15,000£17,500£20,000If required select your sum insuredLevel of cover optionsLevel 1: Fire, smoke, lightning, explosion, earthquake, aircraft impact. Level 2: Fire, smoke, lightning, explosion, earthquake, aircraft impact, storm, flood, collision by any vehicle or animal, subsidence, heave, landslip. Level 3: Fire, smoke, lightning, explosion, earthquake, aircraft impact, storm, flood, escape of water from fixed water tanks, apparatus or pipes, escape of oil from a fixed domestic oil-fired heating installation and smoke damage caused by a fault in any fixed domestic heating installation, theft or attempted theft, collision by any vehicle or animal, malicious damage, subsidence, heave, landslip.Select the level of cover you require?*Level 1Level 2Level 3Voluntary excess (with premium discount)?*£100£250£500£1,000ZeroIn addition to the compulsory excesses About proposer(s) and the property to be insuredAny unspent criminal conviction(s) or prosecution(s) pending?NoYes (give details in box below)Please give details* Ever been declared bankrupt, have any CCJs, IVAs or arrangements with creditors?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 any special terms imposed?NoYes (give details in box below)Please give details* Has the property previously flooded or are you aware of a risk of flooding in the locality?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 visible signs of cracking or within an area subject to subsidence or mining (past or present)?NoYes (give details in box below)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?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 THAT 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.