APPLY ONLINE Proposer Details Date of Birth Is this a joint application? YesNo Date of Birth of Partner Insurance Required From Household Details My home is a —Please choose an option—HouseBungalowCottageFlat Is your flat self contained with a separate entrance? YesNo Is your home built of brick or stone with tile or slate roof? YesNo Is your home used as a private household accommodation for you and your family and not for any business use? YesNo Is your home unoccupied for more than 30 consecutive days? YesNo Is your home left regularly unattended due to all adults being in full time work or education? YesNo Have you or any member of your household... Ever sustained a loss in the last 5 years or any claims pending? YesNo Ever been convicted of any criminal offence or prosecution pending? (excluding driving offences) YesNo Ever had a proposal or renewal declined or special terms or conditions imposed? YesNo Previously been insured for a household policy? YesNo Buildings Insurance Complete this section if you require buildings insurance Cover for building includes Accidental Damage. Policy excess £100, £2500 compulsory claim excess for water damage. (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 YesNo Is your property is a good state of repair and will this be maintained YesNo Does your home include rooms below ground level or situated in a High Water Table area YesNo Do you have a surveyors report and if so may we have a copy which would then be returned to you YesNo If there is any other financial interest for the property e.g. Mortgagees Contents Insurance Policy excess £100 - Water damage excess £250 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 accidental damage (owner occupied properties only) YesNo 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 for owner occupied 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 —Please choose an option—£50£75£100£125£150£175£200£225£250£275£300 All Sections Cover (Buildings, contents, all risks) —Please choose an option—£50£75£100£125£150£175£200£225£250£275£300 Legal Protection DAS LEGAL PROTECTION COVER – This can be added at an annual charge of £18.00 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 YesNo 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. Data Protection Due to the nature of La Fraternelle business and you wanting to engage with us, we have to ensure that you give us consent to process and hold your personal data. Ticking the following box confirms that you have read and agree to our Data Protection Privacy Policy. Checking the box below is evidence that you give your affirmative consent. I confirm that I have read and agree to the Data Protection Privacy Policy and freely give my consent.
Proposer Details Date of Birth Is this a joint application? YesNo Date of Birth of Partner Insurance Required From
Household Details My home is a —Please choose an option—HouseBungalowCottageFlat Is your flat self contained with a separate entrance? YesNo Is your home built of brick or stone with tile or slate roof? YesNo Is your home used as a private household accommodation for you and your family and not for any business use? YesNo Is your home unoccupied for more than 30 consecutive days? YesNo Is your home left regularly unattended due to all adults being in full time work or education? YesNo Have you or any member of your household... Ever sustained a loss in the last 5 years or any claims pending? YesNo Ever been convicted of any criminal offence or prosecution pending? (excluding driving offences) YesNo Ever had a proposal or renewal declined or special terms or conditions imposed? YesNo Previously been insured for a household policy? YesNo
Buildings Insurance Complete this section if you require buildings insurance Cover for building includes Accidental Damage. Policy excess £100, £2500 compulsory claim excess for water damage. (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 YesNo Is your property is a good state of repair and will this be maintained YesNo Does your home include rooms below ground level or situated in a High Water Table area YesNo Do you have a surveyors report and if so may we have a copy which would then be returned to you YesNo If there is any other financial interest for the property e.g. Mortgagees
Contents Insurance Policy excess £100 - Water damage excess £250 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 accidental damage (owner occupied properties only) YesNo 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 for owner occupied 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 —Please choose an option—£50£75£100£125£150£175£200£225£250£275£300 All Sections Cover (Buildings, contents, all risks) —Please choose an option—£50£75£100£125£150£175£200£225£250£275£300
Legal Protection DAS LEGAL PROTECTION COVER – This can be added at an annual charge of £18.00 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 YesNo
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. Data Protection Due to the nature of La Fraternelle business and you wanting to engage with us, we have to ensure that you give us consent to process and hold your personal data. Ticking the following box confirms that you have read and agree to our Data Protection Privacy Policy. Checking the box below is evidence that you give your affirmative consent. I confirm that I have read and agree to the Data Protection Privacy Policy and freely give my consent.
