PRINTINGSERVICES
Large run LITHOGRAPHICPRINT, short run low costDIGITALPRINT–
We canhandle it all!
It is important that the sum insured chosen (in round sumsof£1000) is sufficient to
cover the full replacement costof all yourhouseholdgoods andpersonal effects.
UnderwrittenbyAllianz Insuranceplc.Registered in Englandnumber84638.Registeredoffice:
57 Ladymead,Guildford, SurreyGU11DB,UnitedKingdom.Allianz Insuranceplc is authorised
by theprudentialRegulationAuthority and regulatedby the FinancialConductAuthority and
the PrudentialRegulationAuthority.Allianz Insuranceplc ison the Financial ServicesRegister,
registrationnumber121849.
Declaration
PLEASEUSECAPITALLETTERSWHENFILLING INTHISFORM
Are you a tenantofGloucesterCityHomes?
Your FullName (Mrs/Ms/Miss/Mr/other)
(Joint tenants+Co-habiteesmustbenamed)
Address
PostCode
Telephoneno.
DateofBirth
Email address
Contents Sum Insured required £__________________
If you require anyof the additional coversbelow (at extra cost)please tick the appropriate
box and specify the amountof cover you require
a) Personal Possessions (cover away from thehome)
(available inbandsof£1,000up tomax£3,000)
£
b)GardensHuts,Garages&Greenhouses
£500
c)HearingAids (available inbandsof£1,000up tomax£3,000)
£
d)Wheelchairs (available inbandsof£1,000up tomax£3,000)
£
Do you require extendedAccidentalDamageCover (at extra cost)?
Yes
No
Wheredid youhear about this insurance scheme?
PersonalDetails
PLEASEREADTHEDECLARATIONBELOWCAREFULLYBEFORESIGNING IT
(tobe completed after entering the information requestedopposite andoverleaf)
1.
I/We agree to advise theCompany if anyof the answersgiven above should change.
2.
I/Wedeclare that allquestionshavebeen fully completed and the answers are true and
correct to thebestofmy/our knowledge andbelief. Failure to answer truthfully and
completelymaymean that yourpolicybecomes invalidordoesnotoperate in the event
of a claim. If you are in anydoubtplease contactGloucesterCityHomes,RailwayHouse,
BrutonWay,Gloucester,GL11DG.
3.
I/Wedeclare thatweunderstand the contentsof this completed application including the
important information for applicants at the startof this form.
4.
I/Wedeclare thatAllianz Insuranceplcmay contactmy/ourpresent insurer for further
information.
5.
I/Weundertake topay thepremiumwhen calledupon todo so.
6.
I/Weunderstand that the informationon this form and information about any incident
I/wemaygivedetailsofmaybepassed to IDS Ltd so that they canmake it available to
other insurers. I/We alsounderstand that, in response to any searches thatmaybemade
in connectionwith this applicationor any incident I/wehavegivendetailsof, IDS limited
maypassmy/our insurers information ithas received fromother insurers aboutother
incidents involving anyone insuredunder thepolicy.
SpecialNote
Ifduring theperiodof your insurance cover, yourhome is likely tobeunoccupied (e.g.
throughhospitalisation, extendedholiday) formore than35 consecutivedays youmust
contact theCompany to establishwhether cover can continue.
Signature(s)
Signature(s)
Date
Thisdocument isavailable in largeprintandBraille if required.
Joint tenants shouldboth signunless
theyaremarried toeachother
Joint tenants shouldboth signunless
theyaremarried toeachother
ForOfficeUseOnly
DateReceived:
Premium:
StartDate:
Tobeansweredby theapplicant
PLEASEANSWERALLTHEQUESTIONSBELOW.
WECANONLYCONSIDERYOURAPPLICATIONONCEALL
THESEQUESTIONSHAVEBEENANSWERED.
(Please tick the correctbox in answer to thequestionsbelow)
1.
Is yourhome self-containedwith itsown separate lockable frontdoor?
2.Is thisproperty yourpermanenthome andoccupiedonlyby yourself and
membersof your immediate familynormally livingwith you?
3.Does the amountof insurance youhave chosen cover the full costof replacing
all yourhouseholdgoods andpersonalbelongings?
If youhave answeredNO to anyof the abovequestions,pleasegivemoredetailsbelow
(use a separate sheet ifmore space isneeded).
4.Do you ever leave yourhome emptyorunattended formore
than35days?
5.
Is yourhomeused for running abusiness?
6.Have youor anyone livingwith you everbeen refused insuranceor
had special terms imposedby an insurer?
If youhave answeredYES to anyof the abovequestions,pleasegivemoredetailsbelow
(use a separate sheet ifmore space isneeded).
7.Have any incidentsoccurred in the last three yearswhichwouldhave caused
you tomake a claim forhousehold contentsorpersonal effects,whetheror
not youwere insured at the time?
If youhave answeredYES to the abovequestion,pleasegiveus the following information
(use a separate sheet ifmore space isneeded)
Date(s)of incident(s)
What caused the loss (theft,waterdamage etc.)?
Valueofgoods lostordamaged?
Were you insured at the time?
If so,howmuchdid the insurerspay in settlementof the claim?
Since the losshave all itemswhichweredamaged/lostbeen replaced?
8.Have youor anyone livingwith you everbeen convictedor chargedwith any
offence,other thandrivingoffences,or is anyprosecutionorpolice enquiry
pending?
If youhave answeredYES to the abovequestion,please tellus:
Dateof convictionor charge?
Natureofoffence?
Penalty received (fine, custody etc.)?
Your age at the time?
Yes
No
Yes
No
Yes
No
Yes
No
Allianz Insuranceplc.
Registered inEnglandnumber84638.Registeredoffice:57 Ladymead,Guildford, SurreyGU11DB,UnitedKingdom.
Allianz Insuranceplc isauthorisedby theprudentialRegulationAuthorityand regulatedby the FinancialConductAuthority
and thePrudntialRegulationAuthority.Allianz Insuranceplc ison the Financial ServicesRegister, registrationnumber121849.
101048_v2_HybridSuper+AD+OE_10/13
PayAsYouGo
HomeContents Insurance
Peaceofmindatanaffordable cost
Application
ImportantNotice
DataProtectionAct – InformationUses
For thepurposesof theData ProtectionAct1998, the
DataController in relation to anypersonaldata you supply
isAllianz Insuranceplc.
InsuranceAdministration
The insurer, its associate companies and agentsmayuse
thepersonaldata that you supplied for thepurposeof
insurance administration. Thisdatamaybedisclosed to
the insurers, your intermediary and regulatorybodies for
thepurposeof administering and regulating your
insurance.Your informationmay alsobeused foroffering
renewal, conducting research, statisticalpurposes and
crimeprevention.Wemay share thesedetailswithother
insuranceorganisations (such as LossAdjustors,or
Investigators) tohelphandle claims.Yourpersonaldetails
maybe transferred to countriesoutside the EEA. Theywill
at all timesbeheld securely andhandledwith theutmost
care in accordancewith allprinciplesof theUK law.We
will store yourdetailsbutwillnot keep them for longer
thannecessary.Under the termsof thedata Protection
Act1998 you are entitled to a copyof all the information
wehold about you forwhichwemay charge you a fee.
SensitiveData
Inorder to assess the termsof the insurance contractor
administer claimswhich arise, the insurermayneed to
collectdatawhich theData ProtectionActdefines as
sensitive (such asmedicalhistoryor criminal convictions).
Byproceedingwith this application youwill signify your
consent to such informationbeingprocessedby the
insureror its agents.
FraudPrevention,DetectionandClaimsHistory
Insurerspass information to theClaimsUnderwriting
Exchange register, runby InsuranceDatabase Services Ltd
(IDS Ltd). The aim is tohelpus check informationprovided
and also toprevent fraudulent claims.Wemay at any time
search the register includingwhenwedealwith your
request for insurance.Under the conditionsof yourpolicy
youmust tellus about an incident (such as fireor a theft)
whichmayormaynotgive rise to a claim.When you tell
us about an incidentwewillpass information relating to it
to thedatabase.We can supplymore informationon the
database if you request it.You should show thisnotice to
anyonewhohas an interest inproperty insuredunder this
policy.Allianz Insuranceplcmay seek information from
other insurers and information agencies to check the
information youmayhave supplied andAllianz Insurance
plcmayprovide the information youhave supplied to
other insurers for the samepurpose.
ClaimsHistory
Under the conditionsof yourpolicy youmust tellus
about any insurance related incidents (such as fire,
waterdamage, theftor an accident)whetherornot
theygive rise to a claim.When you tellus about an
incidentwewillpass information relating to it to a
database.
Wemay search thesedatabaseswhen you apply for
insurance, in the eventof any incidentor claim,or at a
timeof renewal to validate your claimshistoryor that
of anyotherpersonorproperty likely tobe involved in
thepolicyor claim.
LawApplicable toContract
The law in the country inwhich you reside at thedateof
contractwill apply.
PayAsYouGo
HomeContents Insurance
Peaceofmindatanaffordable cost
PolicyDocument
your localexperts
Beforeyou ring
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Over85%ofour
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Abbey InsuranceBrokersLimited isauthorisedand regulatedby theFinancialConductAuthority.Registered inNorthern Ireland.CompanyNo.NI053754
*subject to termsandconditions
JustinHillen
GroupComplianceManager
M:07841803848
Abbey InsuranceBrokers
ComplianceDepartment
1aJordanstownRoad
NewtownabbeyBT370QD
T:02890355519
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An Independent School
Established in1906
