Landlord Insurance Application Form Leave this field blank Broker Full Name (optional) Mobile (optional) Email (optional) Applicant Full Name / Insured Name Applicant (DOB) Email Owner Mobile Occupation Correspondence Address & Post Code (optional) Property Address & Post Code Property Description Insured Property Internal Information Property Type Choose Semi Detached Bunglow Terraced Flat Roof Type Choose Gable Flat Shed Roof Maintained By Choose Landlord Leaseholder Agent Tenant Property Managing by Choose Landlord Leaseholder Agent Tenant Purchase Price Rebuilt Cost Purchase Date Built Year Yearly Rent cover (optional) Type of Let Type of Tenant Any tenant Above Any Relationship with Tenant Tenancy agreement with (optional) Rent paid by (optional) Contents Cover Information Full list if required cover only Subsidence Cover? (optional) Accidental Damage Cover ? (optional) Legal Expenses Cover ? (optional) Terrorism Cover ? (optional) Flood Cover (optional) Home Business Cover £ (optional) Money / Valuable Cover£ (optional) Current Insurer Policy Start Date (optional) Policy End Date (optional) Renewal offered Target Amount Claim Information including NCB ** Additional Information to support the application (optional) Consent By ticking this box, I confirm that the client(s) have confirmed that they want to receive emailed information / advice about relevant relevant services and have given their consent to do so. By ticking this box, I confirm that the client(s) have confirmed that they have authorised me to pass their personal information to Businessxbridge for advice about relevant services and have given their consent to do so. By ticking this box,I confirm that the client(s) have confirmed no Bankruptcy proceedings? IVA? CVA? Assignment for the benefit of a creditor? Any pending or recently filed claims or judgments (including CCJs)? If yes, please also provide details in Additionally. IMPORTANT NOTICE: Failure to disclose material facts could result in your contract being invalidated/cancelled, a claim not being paid or difficulty in obtaining insurance in the future. If you are in doubt as to whether a fact is material you should disclose it. A copy of this proposal form is available on written request within three months from the date of this proposal. Full details of the cover provided appears in the policy document, a copy of which is available on request. Telephone calls may be recorded for security and training purposes Submit