aqua : two · aqua: two proposal form 09 13. is your home listed? 14. is your home open to the...

aqua : twoproposal form - household

aqua : two proposal form

02

Please complete and return this form to your insurance intermediary.

The information that you give to us in this form, and via other means, will form the basis of the contract between you and Aqueduct Underwriting Limited (Aqua).

Duty of DisclosureYou must give full and true answers to all questions. Failure to do so may invalidate the insurance and leave you unprotected in the event of a claim. You must disclose all relevant information and material facts in relation to your proposal for insurance. A material fact is one likely to influence our acceptance or assessment of this proposal. If you are in any doubt as to whether a fact is material or not you must disclose it on this form. You should keep all correspondence in connection with your proposal.

Information Exchange and Fraud PreventionInsurers pass information to the Claims and Underwriting Exchange register, run by Insurance Database Services Ltd (IDS Ltd). The aim is to help check information provided and also to prevent fraudulent claims. When we deal with your request for insurance, in the event of a claim or at the time of renewal, we may search the register. When you tell us about an incident which may or may not give rise to a claim, we may pass information relating to it to the register. You can ask for more information about this.

You should show this notice to anyone who has an interest in the property insured under the policy.

Law ApplyingUnless some other law is agreed in writing between you and us, this contract will be governed by English law and practice and to the exclusive jurisdiction of the courts of England and Wales, unless your main residence is in Scotland, Northern Ireland, the Channel Islands or the Isle of Man, and that residence is insured under this policy, in which case the law applicable to that territory will apply and its courts will have exclusive jurisdiction.

Data Protection ActBy signing this form, you consent to allow Aqua, and the third parties acting on our instructions, to use the information it holds on you for purposes of providing insurance and handling the claims that may arise. Your information will be treated in the strictest confidence and in compliance with the Data Protection Act 1998.

Other InsurancesAs well as providing specialist insurance for high value buildings, contents and valuables, Aqua is also able to offer insurance for yachts and high value motor vehicles (including family fleets valued in excess of £100,000 and super-cars). Please contact your insurance intermediary if you would like further information or a quotation.


03

Date on which you would like cover to commence

The policy will run for one year unless otherwise agreed in writing. Cover cannot commence prior to our written acceptance.

Please answer the following questions using capital letters wherever possible. Unless otherwise stated please circle where appropriate.

You may elect to have the policy issued in the name of an individual(s), company or trust. If you require the policy to be issued in the name of an individual(s) then please omit question 4. If cover is to be issued in the name of a company or trust then please omit questions 1, 2 and 3.

TITLE

TITLE

FORENAME

FORENAME

SURNAME

SURNAME

D M YD M Y

DATE OF BIRTH

RELATIONSHIP TO FIRST NAMED PROPOSER

D M YD M Y

D M Y YD M Y Y

DATE OF BIRTH

1. Proposer

2. Joint Proposer

PROPOSER

PROPOSER’S SPOUSE / CIVIL PARTNER

JOINT PROPOSER

3. Occupation including part-time work. Please describe nature of business if not apparent from occupation


04

i. trust, do any trustees or beneficiaries reside at the address to be insured?

a single family group (with domestic staff if applicable)

ii. company, do any directors or employees reside at the address to be insured?

C) IF PROPOSER IS A:

E) ARE THE PEOPLE DETAILED IN 4 D)

Y

Y N/AN

N

Y N/AN

Title Forename(s) Surname Date of Birth Occupation

D) DETAILS OF THE INDIVIDUALS LIVING AS AT THE PREMISES

HOUSE NAME OR NUMBER

STREET

TOWN / CITY

POST CODE

CORRESPONDENCE ADDRESS IF DIFFERENT

5. Address to be insured

A) NAME OF COMPANY OR TRUST

B) ABOUT THE PERSON COMPLETING THIS FORM AND RELATIONSHIP TO COMPANY OR TRUST PROPOSING THIS INSURANCE

FULL NAME

POSITION HELD

4. If the policy is to be in the name of a company or trust (if not than please move to question 5)

D M YD M Y

DATE OF BIRTH


05

Date of Loss Cause / Description Cost

HOME TELEPHONE

MOBILE

EMAIL

FAX

6. Contact Details

a) during the last 5 years suffered any loss, destruction, damage or liability, whether insured or not, which would have been covered by the insurance that you are applying for had it been in force?

b) ever been declared bankrupt, had bankruptcy proceedings taken against them or entered into an arrangement with their creditors?

c) ever been convicted of, or received a police caution for, or charged with but not yet tried for any offence other than a driving offence or a conviction spent under the Rehabilitation of Offenders Act 1974?

d) ever had an insurer; refuse cover, withdraw cover, invoke cancellation, refuse to renew cover or agree to accept cover but only with special terms?

If yes:

7. Have you or any members of your household or occupants of the property:

DETAILS OF PREVENTATIVE MEASURES TAKEN TO AVOID A RECURRENCE

Y

Y

Y

Y

N

N

N

N


06

IF YOU HAVE ANSWERED ‘YES’ TO QUESTIONS 7 B), C) OR D) PLEASE PROVIDE FULL DETAILS HERE

a) built of brick, stone or concrete and roofed with slates, tiles, metal, asphalt or concrete?

8. Is your home:

Y N

b) in a good state of repair and free from damage or defect of any kind?

c) free of cracking and free of signs of landslip, subsidence and heave?

d) in an area free from landslip, subsidence or heave?

e) in an area free from flooding?

Y

Y

Y

Y N

N

N

N


07

IF YOU HAVE ANSWERED ‘NO’ TO QUESTIONS 8 A), B), C) OR D) PLEASE PROVIDE FULL DETAILS HERE

a) ever been subject to underpinning, remedial action of any type or investigation in connection with subsidence, ground heave or landslip?

Y N

Y N

9. Has your property:

IF YOU HAVE ANSWERED ‘YES’ TO QUESTIONS 9 A) OR B) OR 10 PLEASE PROVIDE FULL DETAILS HERE

Do you undertake any business or commercial activity at the property to be insured including its grounds?

Y N

10. Business & commercial activities

b) ever been subject to flooding however caused, including; burst river banks, rising sea levels, storm, inability of ground or drainage to cope with rain (but ignoring escape of water from domestic heating and water supply system)?


08

a) self-contained with its own lockable entrance door?

b) regularly occupied during the day?

Y N

Y N

c) regularly occupied during the night?Y N

d) not left unoccupied for more than 60 consecutive days?Y N

e) not left unoccupied for more than 90 days in any one year or period of insurance?

Y N

f) occupied solely by you and members of your family (including domestic staff)?

Y N

g) your main family home?Y N

11. Is the whole of your property in which your contents and valuables are normally kept;

IF YOU HAVE ANSWERED ‘NO’ TO ANY PART OF QUESTION 11 PLEASE PROVIDE FULL DETAILS HERE


09

13. Is your home listed?

14. Is your home open to the public?

Main property

Extension(s)

12. What year, approximately, was your property built?

15. Do you plan to undertake any building work to the property with an estimated cost of £50,000 or greater, within the next 24 months (other than for routine maintenance, decoration or garden landscaping)?

IF YES, PLEASE PROVIDE DETAILS HERE. WE MAY ASK YOU TO COMPLETE A FURTHER DETAILED QUESTIONNAIRE CONCERNING PLANNED WORKS IN ORDER THAT WE MAY ASSESS THE RISK AND CONFIRM ACCEPTANCE (AND AT WHAT TERMS) IN ADVANCE OF THE COMMENCEMENT OF THE PROJECT.

Y

Y

Y

Y

Y

Y

Y

Y

Y N

Y N

Y N

IF YES, WHAT GRADE?

IF YES, PLEASE PROVIDE DETAILS


10

a) 5 lever mortice deadlocks fitted to all external doors of the building?

a) is it maintained under an annual maintenance contract with a professional alarm specialist?

e) Does the alarm protect all areas where insured items will be located?

b) key operated security locks incorporating security bolt fitted to sliding patio doors (if present)?

b) name and postcode of maintenance company:

Y

Y

N

N

Y N

Y N

Y N

c) multi point deadlocking mechanism comprising of at least 3 locking points to all external UPVC doors (if present)?

c) is the signalling by;

i. Bells only?

ii. Central station to an alarm monitoring station?

iii. Central station via BT Redcare to an alarm monitoring station?

iv. Connected directly to the police?

Y N

d) key operated window locks fitted to all ground floor and easily accessible windows?

Y N

Y N

Y N

Y N

Y N

e) security grills fitted to all ground floor and easily accessible widows?

NB: ‘easily accessible’ windows are all those on ground or basement floors with an opening width or height greater than 30cm located and those on higher floors that are close to flat/gently sloping roofs, drain pipes or balconies

Y N

16. Does the address to be insured have:

17. Does the address to be insured have a burglar alarm system? (If no go to question 18)

Security and Loss Prevention Measures

Locks

Alarms


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b) name and postcode of maintenance company:

d) is the signalling by;

c) is the alarm;

b) how is the safe mounted?

i. Bells only?

i. battery powered

i. wall mounted

ii. Central station to an alarm monitoring station?

ii. mains powered

ii. under floor

iii. freestanding

iii. Central station via BT Redcare to an alarm monitoring station?

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

a) is it maintained under an annual maintenance contract with a professional alarm specialist?

c) what is the approximate age of the safe?

a) make & model?

e) does the alarm protect all areas where insured items will be located?

Y

Y

N

d) is it securely anchored to the building?Y N

N

Y N

Y N

18. Does the address to be insured have a smoke or fire alarm system? (if no go to question 19)

19. Does the address to be insured have a safe? (if no go to question 20)


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20. If the are there any other security or loss prevention features at the address to be insured please detail in the box below

b) £1000 excessa) £250 excess c) £2,500 excess

21. The standard excess (the first amount of a claim that is not covered) is £500 but you may choose a higher excess in return for a premium saving. If you would like an alternative excess, please tick one of the following:

The travel and legal expenses sections as well as some claims involving certain perils carry a different excess. This is explained in the policy documentation and can be discussed with your insurance intermediary.


13

Alternatively, if you are a tenant or leaseholder and require cover solely for the fixtures and fittings of the building that are not covered by a landlord’s, tenants’ association or managing agent’s buildings policy then we can include cover for these ‘Tenant’s Improvements’ under this policy. For example, a leaseholder of a flat may have a significant financial interest in the improvements made to their flat both before and during his/her ownership. These improvements are typically not covered under the Block of Flats policy arranged by the managing agent as this usually covers only the bare shell. In these circumstances, the tenant would be out of pocket in the event of an incident. If you require cover for tenant’s improvements, please consider the cost of replacing kitchen, hard flooring finishes, tiles, bathroom, decorations, etc. and enter the sum insured below.

If you require the interest of a bank, building society or other party with an interest in the building to be noted on the policy then please provide the name and address here:

Buildings

a) main building

b) other permanent structures

c) Tenant’s improvements

22. Please state the sum insured which should be the full rebuilding cost using similar materials to the same standard of finish including removal of debris and professional fees

£

£

£


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Contents

Contents

23. Please state the full sum insured which should represent the replacement cost as new:

£

NB: Contents does not include valuable articles (paintings, statuary, antiques, art, jewellery, watches, precious metals, guns, furs and collections of rare items). We will ask you about these items next.


15

Valuable Articles

24. Please state the full sum insured which should represent:i. the replacement cost as new for jewellery, watches, guns and fursii. the current market value for paintings, statuary, antiques, art, precious metals(non-jewellery items) and collections of stamps, coins and medals

Jewellery: Please split the sum insured between those items, pairs and sets valued at £20,000 and those valued at less than £20,000. NB Jewellery includes watches and costume jewellery.

In respect of the specified items above, please provide a copy of the purchase receipt or valuation to your insurance intermediary.

Specified Sum Insured (items, pairs or sets valued at £10,000 or more)

Unspecified Sum Insured(items, pairs and sets valued at under £10,000 each)

Jewellery covered worldwide £ £

Jewellery covered in home safe only £ £

Jewellery covered in bank safe only £ £

Specified Sum Insured (items, pairs or sets valued at £15,000 or more)

Unspecified Sum Insured(items, pairs and sets valued at under £15,000 each)

Pictures, paintings, sketches £ £

Antique and collectable furniture £ £

Antique clocks and barometers £ £

Rare porcelain, china, glass & fragiles £ £

Statues and sculpture kept indoors £ £

Statues and sculpture kept outdoors £ £

Precious metals (non-jewellery) £ £

Wine collection £ £

Rare or antique book collection £ £

Stamp, coin and medal collection £ £

Furs £ £

Guns £ £

Arms & armour (static display) £ £

Other (please specifiy) £ £

Other Valuables: Please split the sum insured between those items, pairs and sets valued at £25,000 and those valued at less than £25,000


16

Discounts for valuations, photographs and security marking

Premium discounts are available for the following depending on when they were carried out. If you wish to benefit from the saving, please submit a copy of either the whole valuation report (recommended so that your insurance intermediary may check that you are fully covered) or of the summary page(s) (showing the final values, the name of the valuer and date carried out). The discount increases if the contents and/or valuables valuation contains professional photographs or if you can supply confirmation that the items have been security marked by ‘SmartWater’ or ‘IdentiDot’.

a) Full and detailed rebuilding cost valuationb) Contents and/or valuables valuation c) ‘SmartWater’ or ‘IdentiDot’ security markingd) Professional photographs


17

Declaration

Signature

Signature(s) of joint applicant(s) if applicable

Date

Date

Please read all the information that we provided at the beginning and throughout this document and check that the answers that you have supplied are correct. You must give full and true answers to all questions and you must disclose all material facts. A material fact is one likely to influence our acceptance or assessment of this proposal. A space for additional information is available on the following page. If you are unsure whether a fact is material or not you should disclose it. If you do not disclose a material fact, or do not give full and true answers to the questions in this document, your insurance cover may not protect you in the event of a claim. You should keep all correspondence in connection with your proposal.

I / we declare that the answers given in this proposal are true to the best of my / our knowledge and belief.

I / we understand that you may pass information on this form and about any incident I / we have to IDS Ltd so that they can make it available to other insurers. I / we also understand that, in response to any searches you may make in connection with this application or any incident I/we have, IDS Ltd may pass you information it has received from other insurers about other incident(s) involving anyone insured under this policy.

I / we agree to accept the terms and conditions contained in the aqua : two policy applying to this proposal. If I / we agree to transfer to an alternative aqua product, then I / we agree that the information on this form can be used for the purpose of applying for that product and I/we agree to accept the terms and conditions of that product’s policy wording.

A copy of this proposal can be supplied on request, within a period of 3 months after its completion.

D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y


18

PLEASE USE THIS SPACE TO PROVIDE ANY ADDITIONAL INFORMATION OR MATERIAL FACTS IN CONNECTION WITH YOUR PROPOSAL.


19

PLEASE USE THIS SPACE TO PROVIDE ANY ADDITIONAL INFORMATION OR MATERIAL FACTS IN CONNECTION WITH YOUR PROPOSAL.

Aqueduct Underwriting Limitedt +44 (0)20 7397 4404e [email protected]

11/10 ref: 3953

One Whittington AvenueLondon, EC3V 1LEUnited Kingdom

Aqueduct Underwriting Limited is authorised and regulated by the Financial Services Authority in respect of general insurance business.Aqueduct Underwriting Limited is registered in England No. 7189728. Registered Office: One Whittington Avenue, London EC3V 1LE. Aqua is a trading name of Aqueduct Underwriting Limited. Calls may be monitored and recorded for quality assurance purposes.

aqua : two · aqua: two proposal form 09 13. is your home listed? 14. is your home open to the...

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