Main Residence and Annexe Insurance

Please answer the questions carefully and to the best of your knowledge, as our quotation will be based on the details you provide. Incorrect information could lead to an increased premium, claim being declined or invalidate an insurance.

Step 1 of 8 - Your details

Your details
Renewal or cover start date?*
DD slash MM slash YYYY

Quotes valid for up to 21 days
Occupancy of the main property to be insured?*
Details of the occupancy of the main property?*
Occupancy of the annexe to be insured?*
Maximum number of lodger(s) at any one time?*
Address of your home to be insured?*
Enter postcode, then select address from drop-down
England, Wales & mainland Scotland addresses only

Postcode 1st line 2nd line Town / city Postcode
Is the property a current or former working farm?*
Does the property have any barn(s), dairy shed(s) and stable(s)?*
- Barn(s)
- Dairy shed(s)
- Stable(s)
- No barn(s), dairy shed(s) and stable(s)
The approximate size in acre(s) of the land belonging to the property to be insured?*

Enter details of the insurance proposer, with option to include a joint proposer
Title, full first name and surname?*
Title First name Surname
Date of Birth?*
DD
MM
YYYY
Occupation?*
Type to use search 🔍
Email address?*
Enter email Confirm email
Telephone number?*
Please enter a valid phone number in UK format, starting 07, 01, 02 or +44, with no spaces
Joint proposer?
Name?*
Title First name Surname
Date of Birth?*
DD
MM
YYYY
Occupation?*
Type to use search 🔍

Contents insurance, with option to also include cover away from home
Do you require contents insurance?*
Contents sum insured £?*
Input a sum insured to cover all of your contents in the main property, annexe, outbuilding(s) and garage(s)
Accidental damage cover for contents?
Contents voluntary excess (with a premium discount)?*
Valuables single item(s) over £1,500 within your home?
Valuables defined as gold, silver, precious metals or stones, watches, gold and silver plated articles, fur, guns, and firearms, curios, antiques, pictures and other works of art, collections of stamps, coins and medals within your home only

LIST VALUABLES OVER £1,500 WITHIN YOUR HOME*

Description of each item or set over £1,500	New Value £

Description example:
Diamond and platinum ring ✔
Ring ❌
Click on ⨁ sign to add extra item(s)

OPTIONAL COVER AWAY FROM HOME?
Jewellery, watches, personal possessions worn or carried about your person, bicycles, personal money and cards
UNSPECIFIED POSSESSIONS AWAY FROM HOME*
If required select a sum insured
SPECIFIED ITEMS AWAY FROM HOME*
Jewellery, watches, cameras over £1,500. Mobile phones and computers over £750. Hearing aids of any value

LIST SPECIFIED ITEMS AWAY FROM HOME*

Description of each item or set	New Value £

Description example:
Diamond and platinum ring ✔
Ring ❌
Click on ⨁ sign to add extra item(s)

BICYCLES AWAY FROM HOME*

LIST BICYCLES AWAY FROM HOME*

Make and model of each bicycle	New Value £

Input details in each box, as missing information will mean we cannot quote
Click on ⨁ sign to add extra bicycle(s)

PERSONAL MONEY AND CARD AWAY FROM HOME*
Error - cannot proceed
You asked for cover away from home, but said not required to the 4 options

About your home (main property, annexe, brick, stone or concrete outbuildings and domestic garages), the insurance proposer(s) and family member(s) residing at the home address
Is your home in a good state of repair and to your knowledge, free from damage or defect and will you continue to maintain it properly in the future?
Will the main property be unoccupied for a continuous period exceeding 60 consecutive days?*
Please give details*
Will any trade or business be carried out in your home, excluding the residential occupancy of your home and annexe?*
Business use relating to your profession or occupation, not property ownership
Do you plan on carrying out any renovations, conversions, extensions or other structural alterations to your home in the next 12 months?
Please give details*
Has your home ever been damaged by subsidence, heave or landslip, monitored for subsidence, survey reported movement, showing signs of cracking or within an area subject to subsidence?
Please give details*
Are there any trees over 5 metres tall within 5 metres of of your home?

Details of each tree over 5 metres tall within 5 metres?*

If you do not have all the information you can save and return later, as incomplete answers will mean we cannot quote

Click ⨁ to add more row(s)

Tree on your land (Yes or No)?	Species of tree?	Approximate height of the tree?	Approximate distance from your nearest building?

Is your home within 400 metres of any riverbank, sea front, lake, reservoir or quarry?*
Please give details*
Has your home or the neighbouring area ever flooded or in an area at risk of flooding?
Please give details*
Any unspent criminal conviction(s) or prosecution(s) pending?
Please give details*
Ever been declared bankrupt, have any CCJs, IVAs or arrangements with creditors?
Please give details*
Ever had an insurance proposal declined, had a policy cancelled by an insurer, renewal refused or had special terms imposed?
Please give details*
Made any claims under home insurance policy for this or any other property or any incidents of damage or loss not insured, in the last 5 years?

Please give details*

If you do not have all the information you can save and return later, as incomplete answers will mean we cannot quote

Click ⨁ to add more row(s)

Month / Year	Type of Claim / Brief Description	Cost £

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IMPORTANT INFORMATION WHICH MUST BE READ IN FULL
The information contained in this Statement of Fact forms the basis of your policy and is fundamental to the risk assumed by the Insurers. You must notify Ember JD Insurance Brokers immediately if any of the above details are incorrect as your cover might be invalidated if you do not. Misrepresentation We declare that to the best of my knowledge and belief the information I/We have provided in connection with this proposal to Ember JD Insurance Brokers, whether in my own hand or not, is true and complete and I/We have not withheld or misrepresented any information. I/We ask underwriters to act upon the information provided and issue a contract of insurance between us and I/We agree to accept underwriter’s policy terms, conditions and exclusions. I/We consent to the seeking of information from other insurers to check the answers I/We have provided and I/We authorise the giving of such information for such purposes. I/We understand that if I/We have withheld or misrepresented any of the information contained in this proposal, underwriters may be entitled to void the insurance. Data Protection Act 1998 By accepting this Statement of Fact you consent to Ember JD Insurance Brokers using the information we may hold about you for the purpose of providing insurance and handling claims, if any, and to process sensitive personal data about you where this is necessary (for example, health information or criminal convictions). This may mean we have to give some details to third parties involved in providing insurance cover. These may include insurance carriers, third party claims adjusters, fraud detection and prevention services, reinsurance companies and insurance regulatory authorities. Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use by us as set out above. The information provided will be treated in confidence and in compliance with the Data Protection Act 1998. You have the right to apply for a copy of you information (for which we may charge a small fee) and to have any inaccuracies corrected. Basis of Cover I understand that my acceptance of this Statement of Fact does not bind me to complete the insurance but agree that, should a contract of insurance be concluded, this Statement of Fact and the statements made in it and the information provided in connection with it will be relied upon by the underwriters in deciding whether to accept this insurance. Your records You should keep a record (including copies of any letters) of all information supplied to Ember JD Insurance Brokers for the purpose of entering into this insurance. Change in Circumstance You must inform Ember JD Insurance Brokers of any change in circumstances which may affect this insurance. If you are in any doubt you should consult Ember JD Insurance Brokers. The Consumer Insurance (Disclosure and Representations) Act 2012 sets out situations where failure by a policyholder to provide complete and accurate information requested by an insurer allows the insurer to cancel the policy, sometimes back to its start date and to keep any premiums paid. The Act also places a duty on the Insurer to ensure that the questions they ask the policyholder are clear, specific and not misleading. Notice to the Proposer / Insured: The parties are free to choose the law applicable to this insurance contract. Unless specifically agreed to the contrary this insurance shall be subject to English Law. Complaints Any enquiry or complaint should be addressed in the first instance to your broker, Ember JD Insurance Brokers. The process for complaining can be found in the Complaints section of your Policy Wording. The Financial Ombudsman If you are still not satisfied with the way a complaint has been dealt with you may ask The Financial Ombudsman to review your case without prejudice to your rights in law. You can contact The Financial Ombudsman at: The Financial Ombudsman Service Exchange Tower London E14 9SR Telephone: 0800 023 4567 www.financial-ombudsman.org.uk.

INSURANCE SINCE 1919

Step 1 of 8 - Your details

Your details

Enter details of the insurance proposer, with option to include a joint proposer

About the MAIN PROPERTY to be insured

About the ANNEXE to be insured

Enter details about the buildings cover required

Contents insurance, with option to also include cover away from home

Security details

About your home (main property, annexe, brick, stone or concrete outbuildings and domestic garages), the insurance proposer(s) and family member(s) residing at the home address

Property types

○ Commercial Property Insurance
○ Flats Insurance
○ Maisonettes Insurance

Occupancy types

○ Home & Annexe Insurance
○ Let Home Insurance
○ Unoccupied Home Insurance

Specific types

○ Home & Garden Room Insurance
○ Leaseholders Improvements Insurance
○ Single Flat Buildings Insurance

Step 1 of 8 - Your details

Your details

Enter details of the insurance proposer, with option to include a joint proposer

About the MAIN PROPERTY to be insured

About the ANNEXE to be insured

Enter details about the buildings cover required

Contents insurance, with option to also include cover away from home

Security details

About your home (main property, annexe, brick, stone or concrete outbuildings and domestic garages), the insurance proposer(s) and family member(s) residing at the home address

Property types

○ Commercial Property Insurance○ Flats Insurance○ Maisonettes Insurance

Occupancy types

○ Home & Annexe Insurance○ Let Home Insurance○ Unoccupied Home Insurance

Specific types

○ Home & Garden Room Insurance○ Leaseholders Improvements Insurance○ Single Flat Buildings Insurance

○ Commercial Property Insurance
○ Flats Insurance
○ Maisonettes Insurance

○ Home & Annexe Insurance
○ Let Home Insurance
○ Unoccupied Home Insurance

○ Home & Garden Room Insurance
○ Leaseholders Improvements Insurance
○ Single Flat Buildings Insurance