Residential Property Insurance Quote Proposer's Name Address Post Code eMail Telephone Mobile Person to contact Best time for contact? Are you property management agent? Yes   No Property developer? Yes   No Residential property address Post Code What do you estimate the cost of rebuilding the property £ Estimated cost of replacing landlord's household content £ Annual rent £ Loss of rent maximum indemnity period Is Subsidence cover required? Yes   No If yes, have the buildings ever suffered from subsidence damage? Yes   No Is terrorism cover required? Yes   No Should any additional interested party be noted? Yes   No If yes, details Approximate year of build How long owned? Listed building? Yes   No If yes, grade Type of property Detached house Semi detached house Mid terrace house End terrace house Bungalow Single flat Block of flats Other If blocks of flats Number of flats Purpose built Conversion Is the property built; Solely of brick, stone or concrete? Yes   No Roofed with slate, tile or concrete? Yes   No If no, details Is there any flat roof Yes   No If yes, percentage of total roof area and construction Number of storeys PROPERTY Use of property Professional let DSS benefit Student Unoccupied Other Duration of lease agreement Lease agreement between policyholder & tenant? Yes   No If no, details If student let How many students? Is cooking allowed in rooms other than designated kitchens? Yes   No Does the property have appropriate fire and electrical certificates? Yes   No If unoccupied will the property be? Let within 60 days Let within 90 days How long has it been unoccupied? Any works to be undertaken? Yes   No If yes, are they? Internal decoration only Minor renovation Refurbishment (no structural changes) Major renovations Refurbishments (including structural changes) Conversion Extension being constructed Details of any structural work The premises are In a good state or repair and will be so maintained. Heated solely by oil/electricity/mains gas/solid fuel. Not in an area likely to be subject to flooding or where flooding has occurred. Not close to any cliff, quarry or any other excavation. Not showing signs of previous or existing damage by subsidence, landslip or heave, nor any nearby premises. Free from underpinning or any other remedial action. Not situated within 30 feet of any tree or shrub over 20 feet in height. PERSONAL HISTORY The Proposer and any director or partner has not Yes   No Suffered any loss or incurred any loss or liability, whether Insured or not, during the past 5 years in respect of the risks proposed, or had any claims made against you whether at this or any other premises. Yes   No Been convicted of or been charged with, any offence other than driving offences. Yes   No Been declared bankrupt or been a director of any company that went into liquidation. Yes   No Had any Insurance declined, cancelled, refused or discontinued, or had special terms applied by any Insurer for the risks proposed. CLAIMS HISTORY Details of any claims in the past 5 years Date of loss Type of claim Estimated cost £ Have you already been quoted for this insurance? Yes   No If yes, please give premium (inclusive of insurance premium tax) £ Comments   WHITE KNIGHT GROUP Britannia House High Street Bream, Lydney Glos GL15 6JS Tel 01594 563288 Fax 01594 564084 Email brianfrost@whiteknightgroup.co.uk FSA number is 121356 White Knight Group is an independent intermediary authorised and regulated by The Financial Services Authority who also trade under the names of Dean Magna Insurance & Financial Consultants, Farmer & Clark Insurance & Financial Consultants and Swambo Woollett Insurance & Financial Consultants. Please refer to www.fsa.gov.uk for further information.

Data Protection Any personal or financial information supplied to The Group may be stored, used and transmitted to Insurers,Brokers,credit Reference Agencies and Financial Services Institutions in the context of advising/making recommendations on, and arranging transactions and related credit facilities in, General Insurance business on your behalf. Insurers share information with each other via the “Claims and Underwriting Exchange Register” and the “Motor Insurance Anti-fraud and Theft Register” to aid the prevention of fraudulent claims. Disclosure of Material Facts Please advise White Knight Group immediately if any information contained herein is incorrect. This Statement of Fact forms the basis of the Insurance contract. A Material Fact is one likely to influence an Insurer in the assessment and acceptance of the Insurance. All material facts known to you should be disclosed. Should you be in doubt whether or not a fact is material, it should be disclosed for your own protection, since failure to disclose a material fact may invalidate the Policy.

Web Design SOZO