Important Information

This form is designed to capture the information on which the contract of insurance will be based.
Disclosure

All information you provide must be true and correct to the best of your knowledge and belief. Any information that is likely to influence insurers in the assessment or acceptance of your application must be disclosed. If you are in doubt as to whether a fact is relevant you must disclose it.
Section 1 - Proposer Details
Title
 First Name
 Surname
Date Of Birth
Occupation
  		 
Contact Phone number
 Mobile number (Optional)
 Email Address


Section 2 - Joint Proposer Details
Title
 First Name
 Surname
Date Of Birth
 Occupation
 


Section 3 - Risk/ Correspondence Address
Address of the premises to be insured
Town/ City Postcode
Correspondence Address
Town/ City Postcode


Section 4 - Previous History

Have you or any permanent member of your household (please tick all that are relevant)
Ever had a proposal for insurance declined?  Ever had special terms or conditions imposed? 
Ever had renewal refused?   Ever been convicted for any non-motor criminal offences? 
Ever had an insurance cancelled or declared void?  Been cautioned for or charged but not yet tried for any non-motor offences? 
If you have 'ticked' any boxes above, please give further details in Section 13, Additional Information.


Section 5 - Claims History
If you or anyone whose property is to be insured has sustained any loss, damage, or liability for any events that you wish to insure against, whether insured or not, in the last 5 years, please give details:
Date Type of claim/ Loss or Damage Cost
£
£
£
£


Section 6 - Premises Details
Property Type
Detached  Semi-Detached 
Terraced  Semi-Detached Bungalow 
Flat (Purpose Built)  Flat (Conversion) 
Bungalow 
Number of Bedrooms 
Residence
Main  Second Home 
Holiday Home  Let 
   
Listed (if any of the buildings are listed)
1  A 
2  B 
2* 
   
Year Built 
Mortgagee/ Interested Party Details 
Address 
Town/ City  Post Code 
Is the property to be insured and its outbuildings:
Built of brick, stone or concrete and roofed with slates, tiles, asphalt, metal or concrete? Yes  No 
Are there any flat roofs the area of which exceeds 25% of the total roof area? Yes  No 
Free from and in an area historically free from flooding, subsidence, heave, landslip or costal or river erosion? Yes  No 
Is the property to be insured:
Occupied by anyone other than you and your family e.g resident domestic staff, lodgers, tenants or holidaymakers? Yes  No 
Used for business or professional purposes? Yes  No 
A second or holidy home for your own use? Yes  No 
Regularly left unattended for more than 30 consecutive days at any time? Yes  No 
If you have 'ticked' any boxes above, please give further details in Section 13, Additional Information.


Section 7 - Security
Please tick if;
All accessible windows, fanlights and skylights are fitted with key operated locks 
All final exit doors are fitted with atleast 5 lever mortise deadlocks 
If the property does not comply with the above security, please provide details in Section 13, Additional Information.
 
If there is an Alarm or Safe installed at the premises, please complete below:
Signalling
Audible  Dualcom Plus  Central Station 
Digital Communication  Police Direct Line  Redcare GSM 
PAKNET  Redcare 
Intruder Alarms
NSI NACOSS Approved and Maintained  Not Accredited 
SSAIB Approved and Maintained 
If there is a safe installed at the property please provide details in Section 13, Additional Information.


Section 8 - Buildings Insurance
Building Sum Insured (full rebuilding cost of the property) £ 
Building Deductible (the amount of the first part of the loss you wish to bear) £ 
Additional Covers (Sum Insured)
Outbuildings £  other £ 


Section 9 - Contents Insurance
Contents Sum Insured (the cost to replace items at current prices)
(Excluding Fine Art/ Gold, Silver and Plate and Personal Possessions) 		£ 
Contents Deductible (the amount of the first part of the loss you wish to bear) £ 


Section 10 - Fine Art
Sums Insured (the cost to replace items at current prices)
Unspecified Fine Art and Antiques £ 
Unspecified Gold and Silver Plate £ 
Specified Fine Art (Please only specify items that exceed £5,000 in value)
Item Location Description Sum Insured
£ 
£ 
£ 
£ 
£ 


Section 11 - Personal Possessions
Sums Insured (the cost to replace items at current prices)
Unspecified Personal Possessions (excluding jewellery and watches) £ 
Unspecified Jewellery and Watches £ 
Specified Personal Possessions (Please only specify items that exceed £5,000 in value)
Item Location Description Sum Insured
£ 
£ 
£ 
£ 
£ 


Section 12 - Additional Covers
Travel Insurance (cover for all members of your household permanently living with you up to the age of 65)
Please tick, if required
Annual Worldwide Travel Insurance including 17 days of Winter Sports


Section 13 - Additional Information


Section 14 - Declaration

I/We declare that thee information given in this proposal form and any supplementary questionnaire was (whether completed by me/us or not) is, to the best of my/our knowledge and belief, correct and complete and that I/we have read the note headed "Disclosure".

I/We understand that the signing of this proposal form and any supplementary questionnaires does not bind me/us to complete the insurance and that the insurance will not be in force until the proposal has been accepted by Sennocke Private Clients.

By signing this declaration I/We agreed to my/our personal details and those of any persons to be insured being passed to subscribing insurers (or anyone acting on their behalf) solely for the purpose of underwriting, administration and claims handling of any polices issued following my/our completion of this proposal form.
Signature(s) of Proposer(s) Date


 

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Sennocke International Insurance Services Limited is authorised and regulated by the Financial Services Authority. Registered in England with the company number 04693892. Registered office is Anton House, South Park, Sevenoaks, Kent, TN13 1EB Copyright © 2009. All Rights Reserved.