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ImportantNotice

to thedatabase.We can supplymore informationon the database if you request it.You should show thisnotice to anyonewhohas an interest inproperty insuredunder this policy.Allianz Insuranceplcmay seek information from other insurers and information agencies to check the information youmayhave supplied andAllianz Insurance plcmayprovide the information youhave supplied to other insurers for the samepurpose. ClaimsHistory Under the conditionsof yourpolicy youmust tellus about any insurance related incidents (such as fire, waterdamage, theftor an accident)whetherornot theygive rise to a claim.When you tellus about an incidentwewillpass information relating to it to a database.

DataProtectionAct – InformationUses For thepurposesof theData ProtectionAct1998, the DataController in relation to anypersonaldata you supply isAllianz Insuranceplc. InsuranceAdministration The insurer, its associate companies and agentsmayuse thepersonaldata that you supplied for thepurposeof insurance administration. Thisdatamaybedisclosed to the insurers, your intermediary and regulatorybodies for thepurposeof administering and regulating your insurance.Your informationmay alsobeused foroffering renewal, conducting research, statisticalpurposes and crimeprevention.Wemay share thesedetailswithother insuranceorganisations (such as LossAdjustors,or

Declaration PayAsYouGo HomeContents Insurance

PayAsYouGo HomeContents Insurance

PLEASEREADTHEDECLARATIONBELOWCAREFULLYBEFORESIGNING IT

Tobeansweredby theapplicant

(tobe completed after entering the information requestedopposite andoverleaf) 1. I/We agree to advise theCompany if anyof the answersgiven above should change. 2. I/Wedeclare that allquestionshavebeen fully completed and the answers are true and correct to thebestofmy/our knowledge andbelief. Failure to answer truthfully and completelymaymean that yourpolicybecomes invalidordoesnotoperate in the event of a claim. If you are in anydoubtplease contactGloucesterCityHomes,RailwayHouse, BrutonWay,Gloucester,GL11DG. 3. I/Wedeclare thatweunderstand the contentsof this completed application including the important information for applicants at the startof this form. 4. I/Wedeclare thatAllianz Insuranceplcmay contactmy/ourpresent insurer for further information. 5. I/Weundertake topay thepremiumwhen calledupon todo so. 6. I/Weunderstand that the informationon this form and information about any incident I/wemaygivedetailsofmaybepassed to IDS Ltd so that they canmake it available to other insurers. I/We alsounderstand that, in response to any searches thatmaybemade in connectionwith this applicationor any incident I/wehavegivendetailsof, IDS limited maypassmy/our insurers information ithas received fromother insurers aboutother incidents involving anyone insuredunder thepolicy. SpecialNote Ifduring theperiodof your insurance cover, yourhome is likely tobeunoccupied (e.g. throughhospitalisation, extendedholiday) formore than35 consecutivedays youmust contact theCompany to establishwhether cover can continue.

PLEASEANSWERALLTHEQUESTIONSBELOW. WECANONLYCONSIDERYOURAPPLICATIONONCEALL THESEQUESTIONSHAVEBEENANSWERED. (Please tick the correctbox in answer to thequestionsbelow)

No

Yes

PersonalDetails Wemay search thesedatabaseswhen you apply for insurance, in the eventof any incidentor claim,or at a timeof renewal to validate your claimshistoryor that of anyotherpersonorproperty likely tobe involved in thepolicyor claim. LawApplicable toContract The law in the country inwhich you reside at thedateof contractwill apply.

Investigators) tohelphandle claims.Yourpersonaldetails maybe transferred to countriesoutside the EEA. Theywill at all timesbeheld securely andhandledwith theutmost care in accordancewith allprinciplesof theUK law.We will store yourdetailsbutwillnot keep them for longer thannecessary.Under the termsof thedata Protection Act1998 you are entitled to a copyof all the information wehold about you forwhichwemay charge you a fee. SensitiveData Inorder to assess the termsof the insurance contractor administer claimswhich arise, the insurermayneed to collectdatawhich theData ProtectionActdefines as sensitive (such asmedicalhistoryor criminal convictions). Byproceedingwith this application youwill signify your consent to such informationbeingprocessedby the insureror its agents.

PLEASEUSECAPITALLETTERSWHENFILLING INTHISFORM

1. Is yourhome self-containedwith itsown separate lockable frontdoor? 2.Is thisproperty yourpermanenthome andoccupiedonlyby yourself and membersof your immediate familynormally livingwith you? 3.Does the amountof insurance youhave chosen cover the full costof replacing all yourhouseholdgoods andpersonalbelongings? If youhave answeredNO to anyof the abovequestions,pleasegivemoredetailsbelow (use a separate sheet ifmore space isneeded).

Are you a tenantofGloucesterCityHomes? Your FullName (Mrs/Ms/Miss/Mr/other) (Joint tenants+Co-habiteesmustbenamed) Address

your localexperts

No

Yes

PostCode

DateofBirth

4.Do you ever leave yourhome emptyorunattended formore than35days? 5. Is yourhomeused for running abusiness? 6.Have youor anyone livingwith you everbeen refused insuranceor had special terms imposedby an insurer? If youhave answeredYES to anyof the abovequestions,pleasegivemoredetailsbelow (use a separate sheet ifmore space isneeded).

Telephoneno.

Beforeyou ring around, ringus! Over85%ofour renewalcustomers SAVEDon their renewalprice

FraudPrevention,DetectionandClaimsHistory Insurerspass information to theClaimsUnderwriting Exchange register, runby InsuranceDatabase Services Ltd (IDS Ltd). The aim is tohelpus check informationprovided and also toprevent fraudulent claims.Wemay at any time search the register includingwhenwedealwith your request for insurance.Under the conditionsof yourpolicy youmust tellus about an incident (such as fireor a theft) whichmayormaynotgive rise to a claim.When you tell us about an incidentwewillpass information relating to it

Email address

Contents Sum Insured required £__________________ If you require anyof the additional coversbelow (at extra cost)please tick the appropriate

Application

No

£

Yes

box and specify the amountof cover you require a) Personal Possessions (cover away from thehome) (available inbandsof£1,000up tomax£3,000)

£500

Signature(s)

£

7.Have any incidentsoccurred in the last three yearswhichwouldhave caused you tomake a claim forhousehold contentsorpersonal effects,whetheror not youwere insured at the time? If youhave answeredYES to the abovequestion,pleasegiveus the following information (use a separate sheet ifmore space isneeded) Date(s)of incident(s) What caused the loss (theft,waterdamage etc.)? Valueofgoods lostordamaged? Were you insured at the time? If so,howmuchdid the insurerspay in settlementof the claim? Since the losshave all itemswhichweredamaged/lostbeen replaced? 8.Have youor anyone livingwith you everbeen convictedor chargedwith any offence,other thandrivingoffences,or is anyprosecutionorpolice enquiry pending? If youhave answeredYES to the abovequestion,please tellus: Dateof convictionor charge? Natureofoffence? Penalty received (fine, custody etc.)? Your age at the time?

Allianz Insuranceplc.

Signature(s) Peaceofmindatanaffordable cost

£

b)GardensHuts,Garages&Greenhouses

Joint tenants shouldboth signunless theyaremarried toeachother

No

Yes Registered inEnglandnumber84638.Registeredoffice:57 Ladymead,Guildford, SurreyGU11DB,UnitedKingdom. Allianz Insuranceplc isauthorisedby theprudentialRegulationAuthorityand regulatedby the FinancialConductAuthority and thePrudntialRegulationAuthority.Allianz Insuranceplc ison the Financial ServicesRegister, registrationnumber121849. 101048_v2_HybridSuper+AD+OE_10/13

c)HearingAids (available inbandsof£1,000up tomax£3,000) d)Wheelchairs (available inbandsof£1,000up tomax£3,000)

Joint tenants shouldboth signunless theyaremarried toeachother

Do you require extendedAccidentalDamageCover (at extra cost)?

Wheredid youhear about this insurance scheme?

Date

No

Yes

Thisdocument isavailable in largeprintandBraille if required.

It is important that the sum insured chosen (in round sumsof£1000) is sufficient to cover the full replacement costof all yourhouseholdgoods andpersonal effects. UnderwrittenbyAllianz Insuranceplc.Registered in Englandnumber84638.Registeredoffice: 57 Ladymead,Guildford, SurreyGU11DB,UnitedKingdom.Allianz Insuranceplc is authorised by theprudentialRegulationAuthority and regulatedby the FinancialConductAuthority and the PrudentialRegulationAuthority.Allianz Insuranceplc ison the Financial ServicesRegister, registrationnumber121849.

PolicyDocument

ForOfficeUseOnly DateReceived: Premium: StartDate:

Peaceofmindatanaffordable cost

JustinHillen GroupComplianceManager M:07841803848 justin.hillen@abbey-insurance.co.uk

Abbey InsuranceBrokers ComplianceDepartment 1aJordanstownRoad NewtownabbeyBT370QD T:02890355519

Abbey InsuranceBrokersLimited isauthorisedand regulatedby theFinancialConductAuthority.Registered inNorthern Ireland.CompanyNo.NI053754

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T :08000665544 www.abbey-insurance.co.uk

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