**test page **test page Tenants home contents insurance scheme Assumptions and claims historyClaims history(Required) Yes No Unfortunately we are unable to proceed with you application online. This does not automatically mean that you cannot join the scheme. Please call 01462 534 003 to discuss application further. Your full nameFull name(Required) Date of birth(Required) MM slash DD slash YYYY Email address(Required) Phone number(Required) Your domestic partnerFull name Date of birth MM slash DD slash YYYY Is the policy required in joint names? Yes No Is anyone living with you who is over sixty years old ? 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Yes No Required start date MM slash DD slash YYYY Must be a Monday The amount of insurance requiredDo you require personal belongings cover?(Required) Yes No Sum insured required £1,000 £2,000 £3,000 Other Do you require mobility scooter/wheelchair cover?(Required) Yes No Sum insured required £1,000 £2,000 £3,000 Other Do you require hearing aids cover?(Required) Yes No Sum insured required £1,000 £2,000 £3,000 Other Is your home self contained with its own separate lockable front door? Yes No Is this property your permanent home and occupied only by yourself and members of your immediate family normally living with you? Yes No Does the amount of insurance you have chosen cover the full cost of replacing all your household goods and personal belongings? Yes No If you have answered no, to any of the above questions, please give more details below:Do you regularly leave your home empty or unattended for more than 60 days? Yes No Is your home used for running a business? Yes No Have you or anyone living with you ever been refused insurance, had insurance cancelled or had special terms imposed by an insurer? Yes No If you have answered yes, to any of the above questions, please give more details below:Have any incidents occurred in the last five years which would have caused you to make a claim for household contents or personal effects, whether or not you were insured at the time? Yes No If you have answered yes, to any of the above questions, please give more details below:Date of incident MM slash DD slash YYYY What caused the loss ?E.g. theft, water damage etc. Value of goods lost or damagedWere you insured at the time? Yes No If so, how much did the insurers pay in settlement of the claim?If you have had a burglary in the last five years please state Yes No How entry was gained? What additional security has been installed since the incident? E.g. extra locks, alarms etc Have you or anyone living with you ever been convicted or charged with any offence, other than motoring offences, or is any prosecution or police enquiry pending? Yes No Date of conviction or charge MM slash DD slash YYYY Nature of offence Penalty received Amount of fine, length of sentence etc. Your age at the time For additional informationDeclaration I/we declare that the information given is to the best of my/our knowledge and belief correct and complete. If the risk is accepted I/we undertake to pay the premium when called upon to do so. I/We understand that my/our information may also be disclosed to regulatory bodies for the purposes of monitoring and/or enforcing the insuer’s compliance with any regulatory rules/codes I/we have read the information provided under the heading “important information”.You must ensure that your sum(s) insured are not less than the full cost of replacing the goods, failure to do so may invalidate your policy or reduce claims settlements. PhoneThis field is for validation purposes and should be left unchanged. Δ
