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Hepburns Insurance Services Limited - Leasehold Landlord Application Form

Are you domiciled in the European Economic Area?
Yes    No
This cannot be backdated, and the earliest cover can start from is the date this application is recieved by Hepburns
Cover Details
The sums insured will be fixed at £2,000,000 for leasehold liability and £10,000 for contents.
Disclosure of Information
The question on this form relate to facts considered material to underunderwriting the insurance. If you answer them fully and honestly you will be considered to have fulfilled your duty to disclose material facts. Failure to do so may invalidate your insurance. If you are in doubt please advise us.
Have you ever suffered loss whether covered by insurance or not, made any claims or been involved in any incidents which could have resulted in a claim in respect of the risks proposed within the last 3 years?
Yes    No
Have you ever had an insurance proposal or renewal refused, or policy cancelled, or special terms imposed for the risk proposed?
Yes    No
Have you ever been declared bancrupt or currently have any legal insolvency arrangements with creditors?
Yes    No
Have you ever been charged, convicted or cautioned for a crimanal, health & safety, welfare or environmental offence other than Road Traffic Law offences?
Yes    No
Is the property used for short lets (ie Assured Shorthold Tenancy)?
Yes    No
Is the home let to asylum seekers or DSS referrals?
Yes    No
Will the property be unoccupied for a period exceeding 45 days?
Yes    No
Is the property of standard construction of brick, stone or concrete and roofed with slates, tiles?
Yes    No
Notes
Cover will not apply to personal possessions or valuables left at the property. Dependant upon the values insured, certain Minimum Security Standards may apply (Please check with Hepburns Insurance for further details)
Declaration
I/we declare that the information given is, to the best of my/our knowledge and belief, correct and complete. I/we agree that the insurance will not be in force until this application has been accepted by Hepburns.
Annual Premium
Monthly Yearly
Total Premium £ £
Insurance Premium Tax (12% of premium) £ £
Monthly Admin Fee £ £
Total Cost £ £
Select Monthly or Yearly Premium
Bank Details
Extra Information
Data Protection
I agree that the data supplied on this website page will be used exclusively by Hepburns Insurance Services to process the application and will not be used for any other purpose by Hepburns Insurance Services or by third parties such as marketing.