Building Insurance Quote Form

SECTION 2 - The Block(s)
How many buildings need to be covered by the insurance?
Usually 1 unless you are insuring a mixed development. For example, a house converted to flats is 1 building; a purpose built block is 1 building; a flat above a shop is 1 building.
How many flats?
How many houses?
Are there any commercial units?
If you answered yes please provide the number of units and more information below
- Yes
- No
Brief Description
Are the properties to be insured of the same construction?
If you answered NO please provide more information below
- Yes
- No
Brief Description
Building reinstatement declared value (BDV) £
Property owners liability limit £
Do you have any employees in connection with the property?
If you answered YES please provide more information below
- Yes
- No
Brief Description

SECTION 5 - Maintenance & Security
Are there any planned maintenance programmes in place?
- Yes
- No
Is there any major building work planned or underway?
If you answered YES please provide more information below
- Yes
- No
Brief Description
Is there any sign of subsidence, landslip, heave, or movement in the building or immediate neighbouring buildings?
If you answered YES please provide more information below
- Yes
- No
Brief Description

SECTION 6 - Claims History
Have any claims been made for this property in the last 5 year for:
1. Due to flood, subsidence or liability*
- No
- Yes
Date of claim*
MM slash DD slash YYYY
Amount of claim*
Brief Description*
2. Any losses over £10,000*
- No
- Yes
Date of claim*
MM slash DD slash YYYY
Amount of claim*
Brief Description*
3. Any other losses in the past five years*
- No
- Yes
Date of claim(s)*
Amount of claim(s)*
Brief Description*

SECTION 7 - General Disclosure
Has the insured or any member of their family directly connected with the property, or any business partner or director ever been convicted of, or charged with but not yet tried with, a criminal offence (other than motoring offences)?
If you answered YES please provide more information below
- Yes
- No
Brief Description
Has the insured or any member of their family directly connected with the property, or any business partner or director ever been made bankrupt, gone into liquidation or received county court judgements?
If you answered YES please provide more information below
- Yes
- No
Brief Description
Has any insurer ever declined a proposal, refused renewal, terminated cover, required increased premiums or imposed special conditions on the insured?
If you answered YES please provide more information below
- Yes
- No
Brief Description
Are there any other material facts (anything likely to influence an insurer in their assessment and acceptance of the risk) of which the insurer should be made aware?
If you answered YES please provide more information below
- Yes
- No
Brief Description

ADDITIONAL INFORMATION
PRIVACY NOTICE
Deacon is the trading name of Arthur J. Gallagher Insurance Brokers Limited. We are the data controller of any personal information you provide to us or personal information that has been provided to us by a third party. We collect and process information about you in order to arrange insurance policies and to process claims. Your information is also used for business purposes such as fraud prevention and detection and financial management. This may involve sharing your information with third parties such as insurers, reinsurers, other brokers, claims handlers, loss adjusters, credit reference agencies, service providers, professional advisors, our regulators, police and government agencies or fraud prevention agencies. We may record telephone calls to help us monitor and improve the service we provide. For further information on how your information is used and your rights in relation to your information please see our privacy notice at www.deacon.co.uk/privacy-policy/ If you are providing personal data of another individual to us, you must tell them you are providing their information to us and show them a copy of this notice.

DECLARATION
I/We agree that this proposal form together with any other information supplied by me/us shall form the basis of any contract effected thereon. I/We undertake to inform the Underwriters of any material alteration to these facts occurring before the completion of the contract of insurance.
Name(s) of Person, Principal, Partner or Director completing this form*
Date*
DD slash MM slash YYYY

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SECTION 1 - Policy Details