Proposer Details

Date of Birth


Is this a joint application?

Date of Birth of Partner








Insurance Required From

Household Details

My home is a

Is your flat self contained with a separate entrance?

Is your home built of brick or stone with tile or slate roof?

Is your home used as a private household accommodation for you and your family and not for any business use?

Is your home unoccupied for more than 30 consecutive days?

Is your home left regularly unattended due to all adults being in full time work or education?


Have you or any member of your household...

Ever sustained a loss in the last 5 years or any claims pending?

Ever been convicted of any criminal offence or prosecution pending? (excluding driving offences)

Ever had a proposal or renewal declined or special terms or conditions imposed?

Previously been insured for a household policy?

Buildings Insurance

Complete this section if you require buildings insurance

Cover for building includes Accidental Damage (Policy excess £100, £250 compulsory claim excess for water damage applies together with any voluntary excess, subsidence excess £2000)

Please Advise

The sum insured for the home, outbuildings, domestic greenhouses, sheds, garages, walls etc

The sum insured, if required, for loss of income if the property is tenanted (must not exceed 20% of the building sum insured)

The approximate year when your home was built

If known the square footage of the building (all floors) measured externally

How many bedrooms are in the property

Has your home or any building nearby ever been damaged by subsidence, heave or landslip

Is your property is a good state of repair and will this be maintained

Does your home include rooms below ground level or situated in a High Water Table area

Do you have a surveyors report and if so may we have a copy which would then be returned to you

If there is any other financial interest for the property e.g. Mortgagees

Contents Insurance

Complete this section if you require contents insurance

Please Advise

Amount of sum insured for household goods and personal effects (do not include any items insured under the All Risks section)

Do you wish to include cover for theft?

Do you wish to include cover for accidental damage (owner occupied properties only)

If your freezer is less than 10 years old we include cover for loss or damage of foods up to a value of £250 following accidental damage, breakdown, or failure of the public electricity company, at no additional premium. Should you wish this increased, please indicate the additional amount required.

If you wish to include cover for pedal cycles we do require the details requested below, any cycle valued under £1000 will be covered at no additional charge, any cycle whose value exceeds £1000 will be rated as an “All Risks” item.

All Risks Cover

Complete this section for All Risks Cover (cover for valuables and other personal effects away from the home)

Only if you have selected cover for contents you may add this additional cover if required and complete the following

The value of unspecified items such as personal effects, mobile phones, valuables, sports equipment, musical instruments, laptops, ipads, hearing aids etc. The total value of all individual items, valued at less than £1500 each should represent the maximum total sum insured for this section

Specified items (individual valuables including jewellery, laptop computers, cameras etc) whose value exceeds £1500 each, require a full description to be completed below – valuation required for jewellery valued at £2000 or above.

Alternative Accommodation

Complete this section for Alternative Accommodation

Cover under this section is for the cost of alternative accommodation if the insured premises are deemed to be un-inhabitable due to damage caused by any of the insured perils on the policy (not to exceed 20% of the sum insured for buildings or contents/all risks)

Discounts

La Fraternelle Home Insurance can include many discounts for their policies
If you or your partner have answered yes to any listed below, you will be entitled to a discounted premium (total discounts will not exceed 50% of the total premium)

Unite (TGWU)Current/Retired States/Civil Service EmployeeForesters Friendly AssociationBoard of Health EmployeesInvestec EmployeesStates House Tenant/GHAIntertrust EmployeesNorthern Bowling AssociationCricket Umpires AssociationGuernsey Swimming ClubCimandisR G FallaNorthern Trust Ltd Staff MembersRoyal Bank of CanadaABN-AMRORBS International EmployeesNatWest EmployeesGuernsey Private Residential Landlords AssocCredit Suisse EmployeesCarey Olsen & Subsidiaries EmployeesIsle of Sark Shipping EmployeesBank of Butterfield EmployeesSkipton Employees

How did you hear of La Fraternelle

RadioGuernsey PressFacebookWebsiteWork Scheme/AssociationFamily/FriendTelephone Directory/Yellow PagesOther

Voluntary Excess

You will automatically be responsible for the first £100 of each claim under Buildings, Contents or All Risks sections of your policy. (£2000 excess applies for subsidence claims)

If you wish to reduce your premium by paying an increased amount for each claim please indicate the additional amount in the boxes below

Buildings Section Only

All Sections Cover (Buildings, contents, all risks)

Legal Protection

DAS LEGAL PROTECTION COVER – This can be added at an annual charge of £16.00 for the year, which is payable by either adding to the annual premium or with the first months instalment if paying by Direct Debit. This cover is only available for owner occupied properties or for tenants taking out cover for their own contents in rented accommodation

Do you wish to include Legal Protection on your policy

Payment

These details will be destroyed after processing payment.

Select how you would like to pay.





If you wish to pay by annual/monthly Direct Debit please complete the Direct Debit mandate and return it to us with the proposal. (premium must exceed an annual amount of £50.00)

Declaration

The attention of the Proposer is drawn to the necessity to disclose all material facts which are likely to influence the acceptance and assessment of the risk by the Society. A material fact is one that would influence the Society in arriving at a decision to accept or decline this proposal or charge premium at a non-standard rate. If the proposer is in any doubt about the facts being considered material, he/she must disclose them in the Additional Information Section.

I/we declare that the answers and statements given are true to the best of my/our knowledge and that I/we have withheld no information whatever regarding this proposal. I/we agree that the answers given, as well as any proposal or statement made in writing by me/us or any other person acting on my/our behalf, shall form the basis of the Contract between myself/ourselves and the Society and I/we further agree to accept indemnity subject to the conditions in and endorsed on the Society’s policy.

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