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 4DJImportant – 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.