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 4 - Your details 25% Your detailsOur reference number?*Enter 9 digit number, found at the top of emails and letters from Ember JD. If 8-digits please start number with zero Date when permanent resident(s) no longer residing?* Day Month Year Will you the policyholder, or if applicable at least one executor, continue to reside in the United Kingdom?*Yes I/we live in the UKI/we reside in the European Economic Area (EEA)I/we reside outside of the UK and EEAResiding outside the UK, tick the box(es) below to select when appropriate:* The property will be managed by a letting agent local to the property The property will be managed by an appointed family member or friend local to the property I/we have a return date to permanently reside in the UK within the next 12 months I/we have a return date to permanently reside in the UK within the next 24 months I/we have a return date to permanently reside in the UK within the next 36 months I/we are UK citizen(s) with current UK passport(s) I/we will continue to have a current UK bank account Enter details of the insurance proposerName?* Title Select from drop-downMr.Ms.MrsMiss.Dr.Prof.Rev.Executor(s) of the late First name Surname Joint Policyholder?NoYesName?* Title Select from drop-downMr.Mrs.MissMs.Dr.Prof.Rev.Executor(s) of the late First name Surname 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 Enter details about the property to be insuredAddress of property to be insured?Enter postcode, click find address, select from drop-down Postcode 1st line 2nd line Town / city Postcode Reason for the unoccupancy?*Up for saleOwner moved into a care homeLiving with a family memberOwner deceasedInbetween letsPurchased, waiting to move inRenovation / refurbishmentDamage from fire or flood (cannot quote)Is the property 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?*YesNo (cannot quote)Any works, refurbishment or renovations planned during the policy period that exceed £50,000 when undertaken by an independent contractor or £10,000 when undertaken by anyone other than an independent contractor?*NoYes (give details in the box below)Please give details of the works*Approximate cost of the works?How long with the works take approximately?Description of the works? Do you require contents insurance?*YesNoContents sum insured?*Input your sum insured Contents of an empty property would be carpets, curtains, furniture, beds and any free-standing domestic appliances This field is hidden when viewing the formIMPORTANT INFORMATION WHICH MUST BE READ IN FULLIMPORTANT 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 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, 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 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 for the purpose of entering into this insurance. Change in Circumstance You must inform Ember JD of any change in circumstances which may affect this insurance. If you are in any doubt you should consult Ember JD. E.U. Disclosure Clause (UK) 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. The process for complaining directly to Lloyds 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.