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UNOCCUPIED PROPERTY FORM
PROPOSER TYPE
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Individual Proposer
Individual Trading As
Limited Company/LLP
SIPP/TRUST
TITLE
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FORENAME
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SURNAME
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Own House Number or Name
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Own Post Code
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EMAIL ADDRESS
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ARE YOU A PROPERTY DEVELOPER
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YES
NO
ARE YOU A UK RESIDENT?
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YES
NO
INCEPTION DATE
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+
SUFFERED ANY LOSS OR INCURRED ANY LIABILITY. WHETHER INSURED OR NOT, DURING THE LAST 3 YEARS AS A RESULT OF THE RISKS PROPOSED(WHETHER AT THIS OR ANY OTHER PREMISES) OR HAD ANY CLAIMS MADE AGAINST YOU?
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YES
NO
BEEN CONVICTED OF OR IN THE COURSE OF BEING CHARGED WITH ANY OFFENCE(EXCLUDING DRIVING OFFENCES)?
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YES
NO
BEEN DECLARED BANKRUPT OR BEEN A DIRECTOR OF ANY COMPANY THAT WENT INTO LIQUIDATION?
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YES
N0
HAD ANY INSURANCE DECLINED,CANCELLED,REFUSED OR HAD ANY SPECIAL TERMS IMPOSED BY AN INSURER?
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YES
NO
IF YES TO ANY OF THE ABOVE PLEASE GIVE DETAILS AND INCLUDE DATES AND AMOUNTS CLAIMED
0/150 words
RISK ADDRESS POST CODE
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HOUSE NUMBER OR NAME
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YEAR OF BUILD
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IS THE PROPERTY A LISTED BUILDING
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YES
NO
BUILDINGS SUM INSURED
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CONTENTS SUM INSURED
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HOW LONG HAS THE PROERTY BEEN UNOCCUPIED?
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90 DAYS OR LESS
91 DAYS TO A YEAR
1 TO 2 YEARS
2 TO 3 YEARS
3 TO 4 YEARS
4 TO 5 YEARS
5 OR MORE YEARS
WHAT IS THE LONG TERM INTENTION?
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TO BE LET
TO BE SOLD
TO BE OWNER OCCUPIER
HAS THE PROPERTY BEEN BOARDED UP?
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YES
NO
WHAT IS THE PROPERTY TYPE?
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HOUSE
BUNGALOW
PURPOSE BUILT FLAT(S)/MAISONETTE(S)
CONVERTED FLAT(S)/MAISONETTE(S)
BEDSITS
IF APPLICABLE WHAT IS THE TOTAL NUMBER OF FLATS/UNITS IN THE PROPERTY?
No Flat
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
WHAT IS THE TOTAL NUMBER OF FLATS/UNITS TO BE INSURED?
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
IS THE PROERTY IN SCOTLAND?
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YES
NO
WHAT IS THE FLOOR CONSTRUCTION?
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TIMBER
CONCRETE
MIXED
IS THE PROPERTY MORE THAN 4 STOREYS HIGH?
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YES
NO
IS ANY PART OF THE PROPERTY FLAT ROOFED?
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NO
YES 0% - 15%
YES 15% - 30%
YES 30% - 50%
YES OVER 50%
IS THE PROPERTY IN A GOOD STATE OF REPAIR AND WILL SO BE MAINTAINED?
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YES
NO
IS THE PROPERTY HEATED SOLELY BY ELECTRICITY AND/OR MAINS GAS AND/OR SOLID FUEL AND/OR OIL FIRED CENTRAL HEATING?
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YES
NO
IS THE PROPERTY BUILT SOLELY OF BRICK,STONE OR CONCRETE AND IS EITHER FLAT ROOFED OR ROOFED WITH SLATE,TILE OR CONCRETE?
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YES
NO
Are the premises protected by the following security
All external doors and/or shutters fitted with a minimum security level of mortice deadlocks conforming to BS3621 or alternatively,close shackle padlocks with matching locking bar?
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No
Yes
All windows fitted with key operated window locks or alternatively,where locks are not fitted all windows must be screwed shut?
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Yes
No
All letter boxes sealed or fitted internally with a stout steel cage?
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Yes
No
In a position/area likely to be subject to flooding or where flooding occurred ?
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Yes
No
Close to a cliff, quarry or other excavation?
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Yes
No
Having any structural alterations, or major renovation work affecting load bearing walls or the roof, or are any sch works being planned?
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Yes
No
Currently have any other building work undertaken, or planned within the next 12 months, that will cost more than £25,000 (including decoration)?
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Yes
No
Are any nearby premises showing any sign of existing or previous damage by subsidence,heave or landslip?
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Yes
No
Free from any underpinning or any remedial action with regards to Subsidence, Heave or Landslip?
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Yes
No
Is any part of the premises ever used as a second home, holiday let or any commercial business whether to be insured on this policy or not?
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Yes
No
Material Facts Declaration
Do you need to provide any other Material Facts in relation to this proposal form or property?
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