Proposal form

IMPORTANT NOTIcE
Please complete the following information carefully. Your insurance contract will be based on the information disclosed by you as set out in this proposal
form. If you are unsure of answering any questions please contact us and we will be happy to help. We reserve the right to refuse this insurance if information
disclosed renders this risk unacceptable to us. Failure to disclose all material information or any change in the information advised (i.e. information likely
to influence the assessment of this risk) could invalidate the insurance. If you are in any doubt whether any information is material, it should be disclosed.

Rh Specialist Insurance division is a trading style of Willis limited, a lloyd’s broker and authorised and regulated by the financial
Services Authority. Registered office: 51 lime Street, london, Ec3M 7dQ. Registered number 181116 England and Wales. The Rh
insurance schemes are administered on behalf of Willis limited by Equity Red Star Services limited. Equity Red Star Services limited is an
appointed representative of Equity Syndicate Management limited which is authorised and regulated by the financial Services Authority.

Equity Red Star is managed by Equity Syndicate Management limited which is authorised and regulated by the financial Services Authority.
Equity Syndicate Management limited is registered in England & Wales No. 426475. Registered Office: library house, New Road, Brentwood,
Essex, cM14 4gd.

cover will be subject to the terms and conditions in the policy booklet.

dATE cOvER TO cOMMENcE

PERSONAl dETAIlS
Proposer Joint Proposer/Spouse
Title Title
Forename Forename
Surname Surname
Full time occupation Full time occupation
Employers business Employers business
Part time occupation Part time occupation
P/T Employers business P/T Employers business
Date of birth Date of birth
Relationship to proposer

AddRESS
Risk Address (home) correspondence Address
Address Address

Postcode Postcode
Since what date have you Previous address
been resident at the risk
address?

Home Telephone Number

Work Telephone Number
Postcode
 HOME DETAILS yes no
1. Is the home a:
a) house?
b) bungalow?
c) maisonette?
d) flat?
e) other?

2. If the home is a house or bungalow is it:

a) detached?
b) semi-detached?
c) terraced?

3. If the home to be insured is a flat or maisonette is it:

a) in a converted purpose built block?
b) in a converted building?
c) ground floor or basement?

4. In what year approximately was the home built?

5. a) Is the home listed?

b) If the answer is ‘yes’ please state grade of listing:

6. How many bedrooms are in the home (even if not currently used for this purpose)?

7. Is the home self-contained with a separate lockable entrance under your sole control?

8. Are the walls built entirely of brick, stone or concrete (but not pre-fabricated walls or panels)?

9. Is the roof constructed of slate or tile?

10. Is more than 30% of the total roof area flat?

11. Is the home to be insured:

a) in a good state of repair and will it be properly maintained?
b) ever to be left unoccupied for more than 30 days in a row?
c) occupied as your permanent residence solely by you and members of your family?
d) a holiday home used solely by you, your family and friends?
e) a holiday home which is let out?
f) unoccupied?

12. a) Is the home used in any part for business, trade or profession?
b) If the answer is ‘yes’ is the business use restricted to clerical work only?

13. Do you occupy the home as a:

a) homeowner?
b) tenant?

14. If you are a tenant, is the home:

a) rented furnished?
b) rented unfurnished?
c) Local-Authority-owned?
d) Housing Association owned?
e) leased under a tenancy agreement for at least six months?

15. Is the home on a site which has ever shown signs of damage caused by subsidence, heave or landslip, or is there
any evidence of ongoing movement (e.g. cracking and bulging of the walls) or on a site where the properties in the
immediate neighbourhood have been affected by any of these causes?
 HOME DETAILS yes no
16. Is the home free from any previous underpinning or any remedial action of any type in connection with subsidence,
heave, landslip or coastal or river erosion?

17. Is the home within 400 metres of any cliff, riverbank, lake, seafront, reservoir, quarry or other excavation?

18. Is the property in a good state of repair and free from damage or defect in any way?

19. Is the property to be insured free from flooding, in an area that is free from flooding in the last 25 years and not in an
area indicated as a flood risk area by the Environment Agency?

20. How many people normally occupy your home? No of adults/No of children (under 18’s) Adults
Children

21. Have you, or anyone usually living with you:

a) ever been convicted of or charged with (but not tried yet) any offence other than driving offences
(convictions regarded as spent by virtue of the Rehabilitation of Offenders Act 1974 do not need to be disclosed);
b) ever had any County Court judgements or been declared bankrupt;
c) ever had an insurance policy cancelled, refused or had any special conditions or extra precautions applied?

If you have ticked a shaded box then please provide further details here:

22. Have you, or anyone usually living with you suffered any loss, theft, damage, injury or liability in the last 5 years, whether or not the home
was insured? If yes, please provide full details below

CLAIMS HISTORY
Date of Loss Type of Loss Loss Value Section At risk address?

SECURITY yes no
Is the home unoccupied on a daily basis during working hours?
Is the home usually unoccupied at night?
What is the maximum number of days the home will be unoccupied?
Is the home fitted with an approved smoke detector?
Are the security devices activated at night or when the property is unoccupied?
Are approved locks fitted on all external doors that conform to BS3621 and key operated locks fitted to all
accessible windows, patio doors and French/double doors?

If you have ticked a shaded box then please provide further details here:
 PREVIOUS INSURANCE COVER
Buildings
Previous Insurer Previous Policy Number
Expiry Date

Contents
Previous Insurer Previous Policy Number
Expiry Date

BUILDINGS INSURANCE
Is cover required under this section?
Is £500,000 sufficient to cover the full rebuilding cost in the present form of your
buildings including garage and all outbuildings plus an amount for demolition costs,
architects’ and surveyors’ fees?
If you exceed the amount stated above then this policy is not suitable for your requirements and you should speak to us.
Do you require accidental How many claim free
damage cover? years have you earned for
Buildings?
Do you require a voluntary £50
excess required over and above
£100
the standard policy excess?
If so please state amount: £250

Name and address of the Building Society or Mortgage Lending Institution which has a financial interest in the home?
Name Name
Address Address

Postcode Postcode
Reference no. Reference no.
Interest Type Interest Type

CONTENTS INSURANCE (excluding items to be insured under ALL RISKS cover)

Is cover required under this section?
Is £60,000 sufficient to replace all of your household contents as new with the
exception of clothing, where a deduction should be made for wear and tear?

If you exceed the amount stated above then this policy is not suitable for your requirements and you should speak to us.
Do you require accidental How many claim free
damage cover? years have you earned for
Contents?
Do you require a voluntary £50
excess over and above the
£100
standard policy excess?
If so please state amount: £250
The total amount of all high risk items* should not exceed the amount specified for * High Risks Items are Portable entertainment
the number of bedrooms at the home. equipment, video and photographic equipment, articles
of gold, any rare or unusual articles that are collectable,
Up to £6,000 in total if your home has one bedroom silver, precious metals or stones, jewellery, watches,
Up to £7,500 in total if your home has two bedrooms clocks, pictures, drawings, sculptures & paintings, pearls,
Up to £10,000 in total if your home has three bedrooms guns, musical instruments that are designed to be carried.
Up to £15,000 in total if your home has four bedrooms
Up to £17,500 in total if your home has five bedrooms Portable Entertainment Equipment: portable music
and MP3 players, game consoles, tablets and e-readers,
The single article, pair or set limit for any one item is £5,000 unless specified within computing equipment, electronic communication
the home. devices, media players that are designed to be portable
and can be used away from the home.
If you exceed the amount stated above then this policy is not suitable for your requirements and you should speak to us.
 SPECIFIED ITEMS WITHIN THE HOME: Please list any High Risk Items exceeding £5,000
Item No Description Sum insured

ALL RISKS COVER: Cover required away from the home

Is cover required under this section?
The total value of unspecified items (single article limit £2,500)
The total value of specified items (please list below)

SPECIFIED ALL RISKS: Please list any item away from the home exceeding £2,500
Item No Description Sum insured

IMPORTANT NOTES
The details you have provided will be used by Equity Red Star Services Limited to process your request in accordance with the Data Protection Act 1998
and other applicable laws. We share data with approved organisations for underwriting and fraud prevention purposes. Your data may also be processed
outside the European Economic Area. In all instances we take steps to ensure an adequate level of protection is given to your information. In order to
assess the terms of an insurance contract or administer claims that arise, we may need to collect data that the Data Protection Act 1998 defines as sensitive
(such as medical data or criminal convictions). In order to process your information for the purposes of providing insurance and claims handling, it may
be necessary to pass your information to carefully selected third parties and other Group companies. By proceeding with this application you signify your
consent to such information being processed in this way.
If you have any queries, please contact the Company Secretariat at: Equity Insurance Group Limited, Library House, New Road, Brentwood, Essex
CM14 4GD.
Insurers pass information to the Claims and Underwriting Register, run by insurance Database Services Ltd (IDS Ltd.). The aim is to help us check
information provided and also to prevent fraudulent claims. When we deal with your request for insurance, we may search the register. When you tell
us about an incident (such as fire, water damage or theft) which may or may not give rise to a claim, we will 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 property insured under the policy.
Preventing and detecting fraud and claims history
If false or inaccurate information is provided and fraud is identified, details will be passed to fraud prevention agencies. Law enforcement agencies may access
and use this information. We and other organisations may also access and use this information to prevent fraud and money laundering, for example, when:
ff Checking details on proposals and claims; or
ff Checking details on applications for credit facilities
Please contact us at www.equityredstar.co.uk if you want to receive details of the relevant fraud prevention agencies. We and other organisations may
access and use from other countries the information recorded by fraud prevention agencies
In order to protect our policyholders we are members of the Insurance Fraud bureau (IFB). If you suspect insurance fraud is being committed you can call
them on their confidential cheat line 0800 422 0421.
DECLARATION
I/We declare that the above statements are true and complete to the best of my/our knowledge and belief and that no material facts have been withheld,
suppressed or omitted.
I/We declare that the answers in this proposal have been carefully checked and that if any answer has been written by any other person shall for this purpose
be regarded as my/our agent and not the agent of the company.
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 purpose.

signed

dated