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 6 - Your details 16% Your detailsRenewal or cover start date?* DD slash MM slash YYYY Quotes valid for up to 30 daysType of tenants residing in the property to be insured?*Working or retiredStudentsHousing Benefit / Local Housing Allowance claimantsAsylum seekersType to use search 🔍 Number of student tenants residing in the property?* 1 or 2 3 or more Is the tenancy agreement directly between yourself (landlord) and the tenant occupant?*YesNo the agreement is with the housing association or local authorityIs the agreement an Assured Periodic Tenancy Agreement?*YesNoHow is your tenanted property managed?*Letting agent local to the propertyPerson entrusted by me who lives local to the propertyMyself residing outside the UK (cannot quote) Enter details of the insurance proposerIs the property owned by an individual or limited company?*IndividualLimited companyName?* Title Select from drop-downDr.MissMr.Mrs.Ms.Mx.Prof.Rev. Full first name please Surname Name of limited company?*Joint Policyholder?NoYesName?* Title Select from drop-downMr.Mrs.MissMs.Dr.Prof.Rev. First name Surname Do you reside in the United Kingdom?*Yes I live in the UKNoResiding outside the UK, tick the box(es) below where appropriate* I/we are UK citizen(s) with a current UK passport i/we have a current UK bank account I/we live in a country within the European Economic Area I/we live in a country outside Europe Select AllEmail 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, then select address from drop-down Postcode 1st line 2nd line Town / city Postcode Approximate year property built?*Approximate year property purchased?*Number of bedrooms?* 1 2 3 4 5 6 Ownership of the property?*MortgagedOwned outrightType to use search 🔍 Type of property?*Detached houseSemi-detached houseEnd-terraced houseMid-terraced houseDetached bungalowSemi detached bungalowEnd-terraced bungalowMid-terraced bungalowType to use search 🔍 Construction of the external walls?*BrickCobConcreteFlintStoneTimberTimber frame with brick wallsTimber frame with cedar claddingTimber frame with plaster panelsTimber frame with zinc claddingWattle and daubPrefabricated (cannot quote)Type to use search 🔍 Construction of the roof?*Tile or slateAsphaltFelt over timberRubber (EPDM)Single ply membraneZincThatch (cannot quote)Type to use search 🔍 Approximate percentage of any flat roof?*Up to 20%Up to 30%Up to 40%Up to 50%Up to 75%100%Is the property a listed building?NoYes Rebuilding cost of the property?*Input your sum insured Accidental damage cover required for buildings?*Not requiredYesBuildings voluntary excess (with a premium discount)?*£100£250£500£1,000Zero Only answer the following questions if contents cover is requiredDo you require contents insurance?*YesNot requiredContents sum insured?*Input your sum insured Landlord's contents would be carpets, curtains, furniture, beds and any free-standing domestic appliances Accidental damage cover required for contents?Not requiredYesContents voluntary excess (with a premium discount)?*£100£250£500£1,000Zero About the property to be insured and the proposer(s)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)Do you plan on carrying out any renovations, conversions, extensions or other structural alterations to the property in the next 12 months?NoYes (give details in box below)Please give details*Has the property 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?NoYes (give details in box below)Please give details*Are there any trees or shrubs over 5 metres tall within 5 metres of the property?NoYes (give details in box below)Details of each tree over 5 metres tall within 5 metres of the property*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 the property? Add RemoveHas the property or the neighbouring area ever flooded or in an area at risk of flooding?NoYes (give details in box below)Please give details*Any unspent criminal conviction(s) or pending prosecution(s)?NoYes (give details in box below)Please give details*Ever been declared bankrupt, have any CCJs, IVAs or arrangements with creditors?NoYes (give details in box below)Please give details*Ever had an insurance proposal declined, had a policy cancelled by an insurer, renewal refused or had special terms imposed?NoYes (give details in box below)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?NoYes (give details in box below)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 / YearType of Claim / Brief DescriptionCost £ Add RemoveThis 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 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. 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 Insurance Brokers. 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.