CHUResidentsline Buildings Insurance Quotation Form

To obtain a quotation simply complete the form further down this page or Click here to open a “printer friendly” copy of the form which you can print, complete and fax back to us on 01902 710327 or post to us at: FREEPOST RRRT-KHXA-BUHT, CHUResidentsline, 29 Waterloo Road, WOLVERHAMPTON, WV1 4DJ

Company Name
Your Name
Position:
Email:
Postal Address:
Postcode
Tel No:
Where did you hear about Residentsline?
(please select from the drop-down list)
Renewal Date
Current Insurer
Address of Building(s):
Sum Insured and (if shown) Declared Value.
No. of buildings :
Age: if converted, when?
No. of flats : No. of storeys :
CONSTRUCTION
Walls : Roof:
Floors & Stairs : No. of garages :
    Are they in a separate block? Yes No 
       
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) is your property 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 (to where answers given are marked with an asterisk *)
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 Conduct 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 CHUResidentsline Limited t/as CHUResidentsline.

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