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Online Works Questionnaire

All fields marked* are compulsory

Name of Homeowner to be Insured*

Address of Homeowner to be Insured*

Postcode*

Occupation*

Contact phone No*

Contact email*

Address of Property undergoing Works (If different to Q1 above)

Postcode

Approximate age of Property*

Name and address of mortgagee

Name of Contractors

Period of contract From:* To:*

Contract value (Inc VAT) (£)*

What contract conditions, if any, will the work be carried out under? eg. JCT Minor Works, incorporating insuring clause 6.3B*

Do the contract conditions require the insurance to be in joint names with the Contractor?* No Yes

Details of contract works being undertaken*

Will there be any structural work?* No Yes

If "Yes" please provide full details particularly for roof work and underpinning projects

Will there be any use of heat?* No Yes

If "Yes" please define

Are the walls and roof of standard construction?* No Yes

If "No" please give full details of construction (by "standard" we would assume built of brick, stone or concrete and roofed with slate, tile, concrete, metal or asphalt)

Will work involve:

A depth of excavation exceeding 5 metres?* No Yes

Work in or adjacent to water?* No Yes

If either or both, please give details

Existing structure sum insured (please include garages, outbuildings etc if these are to be covered). NB: The sum insured should be the rebuild value (£)*

Describe the location of the site/home, eg. remote, estate, etc.*

Describe the type of building, eg. detached, terraced etc.*

Is the property listed?*
If so, Grade I or II? No Yes, Grade I Yes, Grade II

Are the premises in an area which is free from flooding and not in the vicinity of any rivers, streams or tidal waters?* No Yes

If "No" please give full details

Have the premises ever suffered from flooding, whether insured or not?* No Yes

If "Yes" please give details

Where is the nearest occupied house in relation to the site/home?*

What is the general condition of the existing structure?*

Will any materials be salvaged?* No Yes

If "Yes" please confirm:

Salvage value

Description of types of materials

How the materials be stored?

Will any materials be direct purchases?* No Yes

If "Yes" please confirm:

Purchase value (£)

Description of types of materials

How the materials be stored?

Will you be living in the home during the works?* No Yes

If "No", who is responsible for securing the site each day?

How often is it intended that you or a person acting on your behalf (not the contractor) visit the site?*

Are the contents to remain in the house?* No Yes

What security is in place at the home during works, e.g. alarm, type of door/window locks, etc?*

Have you, or any person living with you at the property during the proposed period of insurance, ever been convicted of any criminal offence?* No Yes

If "Yes" please give details

Have you or any person living with you at the property during the proposed period of insurance, made a claim (whether paid or not) under this or any similar type of insurance in the last 3 years?* No Yes

If "Yes" please give details

When the works are completed, what are your intentions for the property?*

Is there any other information you feel we should know about this request for insurance? Please give details here.

I/we hereby declare that the information given by me/us in this form is answered correctly to the best of my/our knowledge and belief and that I/we have disclosed all *material facts.

*A material fact is one which could affect the Insurer's assessment of the risk proposed.
If you are in any doubt as to whether a fact is material or not, you should declare it or seek the advice of your insurance intermediary.

If you choose to effect insurance with us, this questionnaire will form the basis of the contract.

DATA PROTECTION ACT 1998 - PROPOSER'S CONSENT CLAUSE:
By signing this form and/or making an application for this insurance, I/We hereby consent to any information about me/us being processed by Insurers, Azure Insurance Services Limited or Somerville Market Solutions Limited acting as agent of the Insurers, for the purposes of providing insurance and claims handling, which may necessitate providing such information to third parties.

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