Commercial Combined Proposal

SUBSIDENCE QUESTIONNAIRE (COMMERCIAL USE) FORM

This proposal form is not suitable for private individuals insuring houses/flats that fall into the following situations: 1) The property will be your main residence 2) The property will be a holiday home/second home used solely by you & your family or friends (i.e no commercial lets) 3) The property was last used as your main residence 4) The property was last used as either a holiday home/second home used solely by your & your family or friends (i.e no commercial lets) 5) You are acting as executor/trustee for the management or disposal of a private individual’s main residence 6) You are acting as executor/trustee for the management or disposal of a private individual’s holiday home/second home that was used solely them & their family or friends (i.e no commercial lets)

Please note that in completing this Proposal Form you must disclose all material facts which may influence the acceptance or assessment of the risk. If you are in any doubt as to whether any facts are material, you should for your own protection disclose them, as failure to do so could invalidate the insurance.

1) Full name of Insured (You)

2) Full address of property insured (inc. postcode)

3) Type of property e.g terrace house/retail unit

4) Number of Storeys

5) Approximate age of property

6) Has the property been extended? Yes/No

If yes, please provide details

7) Are there any trees or shrubs within 20 Yes/No metres of the property, which are more than 3 metres tall?

If yes, please provide details, including the type of trees or shrubs nearest to the property and their approximate distance from the property

8a) Is there a swimming pool at the Yes/No property?

8b) If yes, is the swimming pool with an Yes/No enclosed building?

8c) Please advise the distance of the swimming pool from the main property

9a) Has the property ever been Yes/No structurally surveyed?

If yes, please attach a copy of the survey

April 2013 Page 1 of 3 report, if available

9b) Has the property ever been the Yes/No subject of any other survey that mentions settlement or movement of the property?

If yes, please attach a copy of the survey report, if available

10) Are any cliffs, hills, underground Yes/No streams, rivers, seas or similar features nearby?

11) Is the property on a sloping site? Yes/No

12) Are there or have there been any Yes/No mining operations, quarrying operations, underground railways, wells, sewers, reservoirs, salt extraction or other underground activities nearby?

13) Is the property constructed on made Yes/No up ground eg. Filled pit, rubbish tip and the like?

14a) Has the property previously suffered Yes/No from subsidence, landslip or heave?

14b) Has the property any signs of Yes/No damage which may be attributed to subsidence, landslip or heave?

14c) Has the property been monitored for Yes/No subsidence, landslip or heave?

14d) Are you aware of any damage that Yes/No has been experienced in the locality e.g. has any neighbouring property, after enquiry, been subject to any occurrence of subsidence, landslip or heave?

If yes, please provide full details including proximity of building.

14e) Were any special provisions made by Yes/No the builder, or required by or disclosed to the Local Authority, when the plans for the erection of the property were submitted? April 2013 Page 2 of 3 If yes, please provide details

I/We declare that the statements and particulars in this proposal are true and that I/We have not misstated or suppressed any material facts. (N.B A material fact is one likely to influence the acceptance or assessment of this proposal by the Insurer. If you are in any doubt as to what constitutes a material fact you should consult your Insurer or your insurance advisor) I/ We understand that non-disclosure or misrepresentation of any material fact on this application will entitle the Insurer to void the insurance. I/We undertake to inform insurers of any material alteration to these facts occurring before completion of the Contract of Insurance. I/We understand that signing this proposal form does not bind we/us to complete this insurance but agree that should a contract of insurance be conducted, this proposal and the statements made herein shall form the basis of the contract between me/us and the Insurer. I/We hereby consent to any information you have about me/us being processed by you for the purpose of providing insurance and claims handling which may necessitate you providing such information to third parties.

Signed: Date:

April 2013 Page 3 of 3