Unoccupied Property Insurance

Do you wish to charge an additional policy fee (This will be added to the quote/schedule)

What is the renewal or expected start date of this policy

Is the property to be insured owned Privately or by a Company?

Privately
Company

Name of company

Your Title

These should be the details of the main proposer, who must be the owner of the property and/or contents to be insured.

Your First Name

Your Surname

What is your Date of Birth?

Telephone Number

Please note we will only contact you regarding admininstration of your policy unless otherwise agreed by you.

Email address

Correspondence Address:

Please enter the postcode of your correspondence address

Address 1

Address 2

City

County

How long would you like the policy to run?

3 Month
6 Month
1 Year

Interested Parties:

Are there any Interested Parties to be noted against this premises?

Yes
No

Name

Address Line 1

Address Line 2

Town

County

Post Code

Ref

Name

Address Line 1

Address Line 2

Town

County

Post Code

Ref

Additional Information:

I’m happy for Emerald Life to send me information about their products and services including discounts on further purchases?

Promotional Code - please enter if applicable

Personal History:

Are you resident within the United Kingdom, the Channel Islands or the Isle of Man?

Yes
No

’Resident’ means ordinarily resident in the UK, Channel Islands or the Isle of Man for the last six months and registered with a GP.

Do you have a UK Bank Account?

Yes
No

Do you have a UK Representitive responsible for checking on the property?

Yes
No

Have you or any proposed beneficiary of this insurance:

Ever been convicted of or is any prosecution pending for any offence of any kind?

Yes
No

Ever been declared bankrupt?

Yes
No

Ever been involved with a company that has gone into liquidation, receivership or administration?

Yes
No

Ever had any CCJ’s or hold any outstanding arrangements with creditors?

Yes
No

Ever had insurance declined by any insurer?

Yes
No

Ever had insurance refused by any insurer?

Yes
No

Ever had insurance cancelled by any insurer?

Yes
No

Ever had any special terms imposed by any insurer?

Yes
No

If you have answered Yes to any of the questions above, please provide full details

Do you wish to disclose any additional information that you feel may be important to an underwriters assessment of this risk?

Yes
No

Please provide any additional information or further details here

Insurance History:

Is this property currently insured?

Yes
No

Please state the name of the previous insurer?

If there has been no previous insurance cover or if there is a gap in cover since expiry of your last policy, please provide full details

If you or any proposed beneficiary of this insurance, have suffered any loss or incurred any liability, whether insured or not, during the last five years, indicate the number of incidents and provide the details.

Claim 1:

Type of Loss

Date of Loss

Amount of Loss

Claim Status

Claims details

Id

Delete

Claim 2:

Type of Loss

Date of Loss

Amount of Loss

Claim Status

Claims details

Id

Delete

Claim 3:

Type of Loss

Date of Loss

Amount of Loss

Claim Status

Claims details

Id

Delete

Claim 4:

Type of Loss

Date of Loss

Amount of Loss

Claim Status

Claims details

Id

Delete

Client Details

Correspondence Address:

Interested Parties:

Additional Information:

Personal History:

Have you or any proposed beneficiary of this insurance:

Insurance History:

Claim 1:

Claim 2:

Claim 3:

Claim 4: