Client Form

General Information

Relationship Manager(Required)
Company Name(Required)
What Type of Policy Do You Require?

1. Applicant Information

1.1 Client Details

Company Name(Required)
Company Reg
Incorporation Date
Trading Address(Required)
Number of Years Trading
Number of Years Building Experience
Mobile Number
SPV Company? (If YES, please complete Section 1.2)

1.2 Parent / Holding Company Information (If Applicable)

Company Name(Required)
Company Reg
Incorporation Date
Trading Address
Number of Years Trading
Number of Years Building Experience
Mobile Number

1.3 Claims History

Any claims in the last 3 years? (If Yes, please provide details)(Required)

2. Contractor / Builder Details

2.1 Company Details

Company Name(Required)
Company Reg
Incorporation Date
No. Years Trading
No. Years Building Years
Max. file size: 512 MB.
Mobile Number

2.2 Claims History

Any claims in the last 3 years? (If Yes, please provide details)(Required)

2.3 Development Experience

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

3. Development Details

3.1 Units

Housing Association Name
12 Year Cover Required?
Do you require insolvency cover for this policy?
Amount of Cover Required
Is There a Basement?
Do You Have a Tanking Guarantee?
Development Address
Unit Dimensions
Total Sqaure Metres
Details of Build
Is any element of the build for non-residential use? (i.e. Commercial Space)
Current Building Use

3.2 About Your Development Land

Are you aware of any Contamination, currently or historically, on the land or site? (Examples would be Landfill, Heavy Metals, Oils, Tars, Chemical Gases, Asbestos, Radioactive or Other Types of land contamination not listed?

4. Contact Details

Site Contact
Project Manager

5. Duration of Works

5.1 Current Stage of Work

Has Construction Started?
MM slash DD slash YYYY
Details of any work completed to date
Details current stage of construction (e.g. site clearance / demolition etc.)
Completion Date

5.2 Development Phases (If Applicable)

Phase 1
Phase 2
Phase 3

6. Insurance Required

Building Cost Per Unit
Total Building Cost - Contract Sum
Existing Structure Value
Sum To Be Insured

7. Premises Information

8. Building Control Function

8.1 Warranty Inspector

8.2 Local Authority and Building Control

9. Declaration

We will process any personal information we obtain in the course of providing our services to you in accordance with the general data protection regulation (GDPR). In administering your insurances it will be necessary for us to pass such information to insurers and other product or service providers which may also provide us with business and compliance support. We may also disclose details to relevant parties, as necessary, to comply with regulatory or legal requirements. We may contact you or pass your details to other companies associated with us in order to promote products or services which may be of interest to you. We will not otherwise use or disclose the personal information we hold without your consent. Some of the details you may be asked to give us, such as information about offences, are defined by the act as sensitive personal data. By giving us such information, you signify your consent to it being processed by us in arranging and administering your insurances. Subject to certain exceptions, you will be entitled to have access to your personal and sensitive personal. If at any time you Wish us, or any company associated with us, to cease processing any of the personal data or sensitive personal data we hold, Or to cease contacting you about products and services, please write to us at our Warrington office, as above.(Required)

9.1 General Data Protection Regulation

During the last three years, have you sustained any losses or had any claims that would be covered by this type of insurance?(Required)
Has any directory, partner or principle ever been convicted or is there any prosecution pending for any offence involving dishonesty of any kind?(Required)
Have you ever been prosecuted or received notification of intended prosecution under the Health and Safety At Work Act 1974, or Consumer Protection Act 1987?(Required)

9.2 Your Declaration

I/We undersigned certify that all details in this proposal form are complete and true.(Required)
To the best of my/our knowledge, no material information relating to the risk has been voluntarily with-held or omitted/(Required)
I/We understand that the signing of this proposal form does not bind us to effect any policy of insurance but agree that if any quotation is accepted, this proposal form and the statements made within shall form the basis of the contract between me/us and the insurers.(Required)
Full Name
MM slash DD slash YYYY

This quote is indicative and subject to all relevant supporting information being provided as per this application form. No policy will be incepted until all drawings, plans, membership form, consumer code and other requested documentation has been provided.

Continuation Sheet