Vacant / Unnoccupied Property Insurance Quote

Title

Sex

-- Please select -- Male Female

First Name(s)

Date of Offence

Date of Conviction

Type of Conviction

(e.g GBH, Common Assault)

Sentence given by court

(e.g. 5 years custodial or 100 hrs community service)

Sentence actually served

(e.g. served 2 years then 3 months on tag)

Description of Incident

(Please give as much information as possible)

Mitigating Circumstance

(e.g. had drink problem at time now recovering alcoholic etc.)

For how long has the property been unoccupied?

What is the long term intention?

You or any other joint owners have never:

1. Suffered any loss or incurred any liability, whether insured or not, during the last 3 years as a result of the risks proposed (whether at this or any other premises) or had any claims made against you?
2. Been convicted of, or in the course of being charged with, any offence (excluding driving offences) whether at these premises or elsewhere?
3. Been declared bankrupt or been a director of any company that went into liquidation?
4. Had any insurance declined, cancelled, refused or had any special terms applied by any Insurer for the risks proposed?

The premises are:

- In a good state of repair and will be so maintained
- Heated solely by oil and/or electricity and/or mains gas and/or solid fuel
- Not close to cliff, quarry or other excavation
- Are not showing any sign of existing or previous damage by Subsidence, Heave or Landslip
- Free from any underpinning or any remedial action with regard to subsidence, heave or landslip

- No part of the property is used for commercial business
- No structural alterations or renovations involving load bearing wall are in progress or planned
- No part of the property is flat roofed

Do you agree with the above statements? Yes No

If no, please state reasons why: