Non Standard Leisure Homes Proposal Form v3

Proposal Form

Non-Standard Leisure Home Insurance

For Non-Standard property used as Leisure Home of the Insured in the UK
It is important that all questions in this proposal are answered accurately. Please provide separately any other information you think might be material to our understanding of your requirements.

Your completing this form in detail will enable us to match your insurance to your needs.
Are you a Broker/Intermediary: *

Yes No

Your Information

First Proposer *

	Details
Title
First Name
Surname
Date of Birth
Occupation
Length of residency in UK

Is there a Second Proposer? *

Yes No

Correspondence Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number
Mobile Number:
E-mail

Confirmation Email
What date do you want your insurance to start?: *

- Day - Month Year

Insured Address: *

Address 1
Address 2
City	County
Postcode	Country

Plot Number & Site Name: *
Have you or any person residing with you, ever been cautioned of any offence other than motoring convictions or have any prosecutions pending?: *

Yes No
If yes, please provide full information:
Has any insurer declined to accept, refused to renew, cancelled or only agreed to continue on special terms any insurance for You or any other person to whom this insurance applies?: *

Yes No
If yes, please provide full information:
Have you or any other person whose property is to be insured ever been made bankrupt or have any unresolved CCJs?: *

Yes No
If yes, please provide full information:
Have you or anyone living with you made any claims or sustained any losses in the past 3 years that would have been covered by this insurance had it been in force?: *

Yes No
If No, for how many years have you held insurance without a claim?
If yes, please provide details:
Bordengate Insurance and BGi.UK are trading styles of H J Roelofs (UK) Ltd which is authorised and regulated by the Financial Conduct Authority (FCA). Our Financial Services register number is 307129. Company Registration no. 3464365

Terms & conditions on www.bgi.uk.com and available on request.

	Details
Type of Property
Construction Type
Name of Manufacturer
Model name or Property Description
Chassis / Serial Number / ID Reference
Year of Manufacture
Length (Feet)
Width (Feet)

Declarations
Important: No list of questions can be exhaustive and we must ask you to consider carefully whether there is any information not given herein which could influence our acceptance of this proposal. Material information includes any special, unusual or otherwise relevant features of the property, its occupation or its location which might make losses more likely to happen or to be more serious or costly than might otherwise be anticipated. You should disclose any information which might be relevant. Failure to do so could invalidate your policy.

Declaration: I declare that to the best of my knowledge and belief that the answers herein are true and that all material information has been fully disclosed. I agree that this proposal is for insurance in the normal terms and conditions of the insurer's policy and shall be incorporated into and form part of the insurance contract. I undertake to inform insurers, in writing (email included) and immediately, of all changes before and during the policy period.

Notice: The information provided on this proposal form will be made available to any other insurer, broker or authority who might make an enquiry regarding the veracity of statements made regarding the information provided in any proposal form, claim form or other document or any statement made orally or electronically.
Declaration:

I acknowledge that the information here-in is true and correct and forms the basis on which the insurance is provided.
Date Form Completed:

- Day - Month Year
Enter the message as it's shown *
One of our Omar Insurance team members will contact you on receipt of your form.
To complete your application, email Omarinsurance@BGi.uk.com with the following and enclose the ID number you will receive on submission of the form:
1. A photo of the exterior of your home
2. A photo of the interior of your home
3. Any additional material information
Alternatively you may wish to post the documents to:

Omar Insurance
Portwell House
26 Market Place Faringdon
Oxon
SN7 7HU

Please ensure you quote the ID number you will receive on submission of your form with any and all further correspondence.
Bordengate Insurance and BGi.UK are trading styles of H J Roelofs (UK) Ltd which is authorised and regulated by the Financial Conduct Authority (FCA). Oour Financial Services register number is 307129. Company Registration no. 3464365

Terms & conditions on www.bgi.uk.com and available on request.
Should be Empty:

	Yes	No
Electric
Gas (Mains)
Oil
Solid Fuel
Bottled Gas

	Yes	No
NCC Registered Park
Gold Shield Registered Park
David Bellamy Conservation Awarded Park
Unregistered Permanent Residence Park
Farm
Private Land (Permanent Residence)
Private Land with Construction Works
Other

Proposal Form

Non-Standard Leisure Home Insurance

For Non-Standard property used as Leisure Home of the Insured in the UK

Your Information

Property Details

Park Details:

Insurance Cover Required

Buildings & Contents

Additional cover away from Home

Unspecified Cover

Specified Cover

Declarations

	Yes	No
Anywhere in Europe
Anywhere within the Rest of the World for a maximum of 30 days

	Yes	No
Accidental Damage when Let (Up to a limit of £5000)
Malicious Damage by hirers (Up to a limit of £2500)

	Yes	No
30 consecutive days
3 consecutive days between 31st October - 31st March

	Yes	No
You have complied with and will continue to comply with the conditions of the Manufacturer's Owner's Handbook and Warranty Obligations
The base has been installed in accordance with the Manufacturer's Siting and Warranty Obligations