Residentsline 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, Residentsline, 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)	RL Marketing 2011GoogleYahooOther Search EngineFlat Living MagazineFlat Living WebsiteRecommended by AgentRecommended by FriendExisting CustomerExisting Agent
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 :	TimberConcreteTimber/ConcreteOther	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 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.