Household Insurance Quotation Form Reference: IntFree Return by 31st October 2009 and you will be eligible for the offer until 31st August 2010 Policyholder details Joint Insured details (if applicable) Name: Name: Date of birth: Date of birth: Occupation: Occupation: Correspondence Insured address: Property Address: (If different) Telephone number: Email address: When is the best time for us to contact you? Buildings Contents Combined Do your existing policies include Accidental Damage cover? What are your current renewal dates? What are your current household premiums? Who is your existing insurer for each of the above? In what year was your home built? Please state the type of building (i.e Semi-detached house, bungalow, flat) Please state number of bedrooms in the property Are any building works currently in progress? If yes please give full details below Please answer YES or NO to indicate if the property to be insured is: YES NO Of standard construction and in good state of repair? Used for business purposes or open to the public? Occupied as your permanent residence? Left unattended for more than 30 consecutive days? Free from subsidence, ground heave or landslip? In an area which is free from flooding? Fitted with 5 lever mortice deadlocks? Fitted with a burglar alarm? Smoke detectors on all levels? Smoke detectors on partial levels only? Have you made any claims in the last 5 years? Are there any trees within 7 metres of the property which are taller than the house? Is there a safe installed? If you have answered YES or NO in any of the shaded boxes in respect of the above questions about the property please provide full details in the additional information box below. Additional information Please indicate the sums to be insured as follows: Buildings £ General Contents (total in the home) £ Computer Equipment £ Personal effects (total to be covered outside the home) £ Pedal cycles £ Jewellery (total to be covered inside the home) £ Jewellery (total to be covered outside the home) £ Furs £ Frozen Food Cover £ If you require cover for frozen foods please provide the age of your freezer Please answer YES or NO to the following additional questions: YES NO Do you require accidental damage cover for your buildings? Do you require accidental damage cover for your contents? Is your home or part of used for business purposes? Does the total amount of all valuables* amount to £5,000 or 20% of the contents sum insured? Does any single item of valuables* (including pairs or sets) exceed £1,500? *Definition of valuables - This refers to jewellery, furs, gold, silver, gold and silver plated articles and pictures. If you have answered YES to either of the above questions in either one of the shaded boxes then please provide additional details in the Additional Information box below. Additional information Cover is subject to underwriters acceptance, terms and conditions. Please return your completed quotation form by email Diabetes@heathlambert.com by fax 01603 625 230 or post: Diabetes UK Insurance Services, Grosvenor House, 112-114 Prince of Wales Road, Norwich NR1 1NS. Diabetes UK Insurance Services is a trading name of Heath Lambert Limited, which is authorised and regulated by the Financial Services Authority. Registered Office: 133 Houndsditch, London EC3A 7AH. Registered Number: 1199129 England and Wales. Data Protection Act 1998 Both parties shall comply at all times with the Data Protection Act 1998 (DPA) and any regulations made under the DPA and in particular with the data protection principles set out in the DPA and with all relevant guidelines and guidance notes issued from time to time by the Information Commissioner, as applicable to each of those parties. Where personal data is supplied or disclosed by one party to the other, the other party will: a) ensure that such personal data is only used for the purposes for which appropriate consent has been given by the data subject; and b) notify the disclosing party of any request it receives from data subjects for subject access or changes to such personal data under the DPA or any correspondence with the Information Commissioner in relation to such personal data.
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