Residentsline Buildings Insurance Quotation Form

Simply print and complete this form and fax back to us on 01902 710327
or post to us at:

FREEPOST RRRT-KHXA-BUHT, Residentsline, 29 Waterloo Road, WOLVERHAMPTON, WV1 4DJ

 

 
PAGE 1
 
Company name:
  
   
 
Your Name:
  
   
 
Your Position:
  
     
Your Email Address:
  
     
 
Your Postal Address:
  
       
  Your Postcode:  
       
  Your Tel No:  
       
  ABOUT THE BUILDINGS TO BE INSURED
       
  Renewal Date:  
       
  Current Insurer:  
       
  Sum Insured:  
       
  and (if shown)
Declared value:		  
       
 
Address of Building (s) to be insured:		  
 
 
  PAGE 2
   
  ABOUT THE BUILDINGS TO BE INSURED (CONTINUED)
   
  Age of the building:       if converted, when?
           
  No. of flats :       No. of storeys : 
           
  CONSTRUCTION        
 
Walls :
       Roof:
           
 
Floors & Stairs :
      
           
  1. Is the property to be insured:  
     
  a. purpose built flats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES   NO
     
  b. a private dwelling converted into flats. . . . . . . . . . . . . . . . . . . YES   NO
     
  c. other, please describe:
     
  d. in a good state of repair and occupied solely as private residences NOT being:
     
    i.   Holiday homes?
  ii.  Bedsits/student accommodation?
  iii. Hostel and/or used as homes by the local government or
      Charitable Organisations?		 YES     NO *
           
  e. currently , or has it ever been affected by subsidence, ground
    heave, landslip, storm or flood?		 YES *   NO  
   
  f.  currently undergoing renovation, repair conversion, or alteration
     or is any such work anticipated in the next 12 months?		 YES *    NO
   
  2. Are there any communal facilities? (lift, boiler, tennis courts,
   swimming pool etc)		 YES *    NO
   
  3. Is there any commercial use? (i.e. shops, offices, restaurants) YES *    NO
   
  4. Have you ever been refused insurance or had special
    terms/conditions imposed?		 YES *    NO
     
  5. Have you sustained any losses involving the risks proposed, or
    had any claim in the last 3 years?		 YES *    NO
     
 
Additional information must be given in the box at the top of page 3 where answers above
are marked with an asterisk * (see above)
           
 
PAGE 3
 
  ABOUT THE BUILDINGS TO BE INSURED (CONTINUED)
   
 
Please give additional information in the box at the below where answers on page 2 were marked with an asterisk (*)
           
 
           
           
  Signed:  
       
  Date:  
       
 
Please fax this form back to us on 01902 710327
or post to us at:
Residentsline, FREEPOST (RRRT-KHXA-BUHT), Wolverhampton, WV1 1BR
       
       

Important - Disclosure: All material facts must be disclosed. Failure to do so could invalidate the policy. A material fact is one which is likely to influence an Insurer in the acceptance and assessment of this application. If you are in any doubt as to whether a fact is material then it should be disclosed to the Insurer. If any changes in circumstances arise during the period of insurance cover please provide your Insurer with details. A specimen copy of the policy wording is available on request. We recommend you keep a record (including copies of letters) of all information provided to the Insurer for your future reference. A copy of the completed application form will be supplied on request within a period of three months after its completion.

Declaration: I/We understand the contents of the completed application and I/we declare that the information given is, to the best of my/our knowledge and belief correct and complete. I/We agree that the statements in this application shall form the basis of the contract between the Insurer and myself/ourselves and if the risk is accepted I/we undertake to pay the premium when called upon to do so. I/We understand that my/our information may also be disclosed to the Financial Services Authority and other regulatory bodies for the purposes of monitoring and/or enforcing the Insurer's compliance with any regulatory rules or codes.

Data Protection - Information Uses: For the purposes of the Data Protection Act 1998, The Data Controller in relation to any personal data you supply is Aviva Insurance Limited.