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(Subject to the terms, exclusions and conditions of the policy, a specimen of which is available on request).
Before you fill in the form, read the declaration at the end.
Make sure that you answer all the questions as fully as possible.
Please return the whole completed form to the Administrator.
Once completed you can email the form directly to the Administrator or if you prefer, print and return the whole completed
form to the Administrator, Housing Income Team, Norwich City Council, St Peters Street, Norwich NR2 1NH.
Please keep a copy of this form together with any information you send with it. Or you can ask for a copy from the insurance
company within three months of taking out insurance.
This form is used to work out your insurance premium and whether you can be insured. Please include all information.If you are in any doubt
about whether to include information, please include it. If you do not it may mean that any claim you make is turned down or reduced.
The Amount of Insurance Required (your sum insured) to the nearest £1,000
£
Name
Your Full Name
Mr Mrs Miss Ms Other
Mr Mrs Miss Ms Other
Name
Your domestic partner or joint proposer, Full name
Is the policy required in joint names? Yes No
Are you a tenant of Norwich City Council?
Yes No
Please tick if you or anyone permanently living with you is over 60?
Yes No
City
Email
Postcode
Tel
Full Address
House number Street
Do you require Wheelchairs cover?* Yes No If yes, tick sum insured required £1,000 £2,000 £3,000
Do you require Hearing Aids cover?
*
Insurance starts when the Administrator informs you that you have been accepted onto the scheme. You will be sent a policy booklet and schedule which
will confirm the sum insured, premium and start date. It is important that the sum insured chosen (in round sums of £1,000) is sufficient to cover the full
replacement cost of all your household goods and personal effects.
*Available at an extra cost as per the table on the previous page. For further details please contact the Administrator.
Yes No If yes, tick sum insured required £1,000 £2,000 £3,000
Date of Birth
Required start date
(must be a Monday)
DDM M Y Y YY
DDMMY Y Y Y
Date of Birth
DDM M Y Y YY
Norwich City Council
Tenants Home Contents Insurance Scheme Application
This is a fillable PDF form. Please download or open the file directly in Adobe Reader
to fill it out. To complete this form electronically, please click on the fields you wish
to complete and type in your answers.
Click the submit button on the last page to send this pdf via email back to us.
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4 Do you regularly leave your home empty or unattended for more than 60 days? Yes No
5 Is your home used for running a business?
Yes No
6 Have you or anyone living with you ever been refused insurance, had insurance cancelled or had special terms imposed by an insurer?
Yes No
If you have answered Yes, to any of the above questions, please give more details below (Please provide full details on page 3 (additional information).
8 If you have had a burglary in the last five years please state
Yes No
7 Have any incidents occurred in the last five years which would have caused you to make a claim for household contents or
personal effects, whether or not you were insured at the time?
Yes No
If you have answered Yes, to the above question, please give us the following information (Please provide full details on page 3 (additional information).
Date(s) of incident(s)
What caused the loss (theft, water damage etc.)?
Value of goods lost or damaged
How entry was gained?
What additional security has been installed since the incident? (extra locks, alarms etc.)
Were you insured at the time?
If so, how much did the insurers pay in settlement of the claim?
Yes No
£
9 Have you or anyone living with you ever been convicted or charged with any offence, other than motoring offences, or is any
prosecution or police enquiry pending?
Yes No
If you have answered Yes, to the above question, please tell us:
Penalty received (amount of fine, length of sentence etc.)
Your age at the time
Nature of offence
1 Is your home self contained with its own separate lockable front door?
Yes No
2 Is this property your permanent home and occupied only by yourself and members of your immediate family normally living with you?
Yes No
3 Does the amount of insurance you have chosen cover the full cost of replacing all your household goods and personal belongings?
Yes No
Please answer all the questions below. We can only consider your application once these questions have been answered.
Please use capital letters when filling in this form.
To be answered by the applicant (please tick the correct box in answer to the questions below)
We can only consider your application once all these questions are answered in full.
If you have answered No, to any of the above questions, please give more details below (Please provide full details on page 3 (additional information).
Date of conviction or charge
DDM M Y Y YY
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For additional information
Important Information
Data Protection Act – Information Uses
For the purposes of the Data Protection Act 1998 the Data Controllers in relation to any personal data you supply are Aviva Insurance Limited and Norwich
City Council.
Insurance Administration
Your information may be used for the purposes of insurance administration by the insurer, its associated companies and agents, by reinsurers and your
intermediary. It may be disclosed to regulatory bodies for the purposes of monitoring and/or enforcing the insurer’s compliance with any regulatory
rules/codes. Your information may also be used for research and statistical purposes and crime prevention. It may be transferred to any country, including
countries outside the European Economic Area for any of these purposes and for systems administration. Where this happens, we will ensure that anyone to
whom we pass your information agrees to treat your information with the same level of protection as if we were dealing with it.
If you give us information about another person, in doing so you confirm that they have given you permission to provide it to us and for us to be able to process
their personal data (including any sensitive personal data) and also that you have told them who we are and what we will use their data for, as set out in this notice.
In the case of personal data, with limited exceptions, and on payment of the appropriate fee, you have the right to access and if necessary rectify information
held about you.
In assessing your application, the insurer or its agents may undertake checks against any publicly available information (such as electoral roll, county court
judgements, bankruptcy orders or repossessions). Similar checks may be made in assessing any claims made.
Information may also be shared with other insurers either directly or via those acting for the insurer (such as loss adjusters or investigators).
Sensitive Data
In order to assess the terms of the insurance contract or administer claims that arise, the insurer may need to collect data that the Data Protection Act defines
as sensitive (such as medical history or criminal convictions). By proceeding with this insurance, you will signify your consent to such information being
processed by the insurer or its agents.
Fraud Prevention and Detection
In order to prevent and detect fraud we may at any time:
Share information about you with other organisations and public bodies including the Police;
Undertake credit searches and additional fraud searches;
Check and/or file your details with fraud prevention agencies and databases, and if you give us false or inaccurate information and we suspect fraud,
we will record this to prevent fraud and money laundering.
We can supply on request further details of the agencies and databases we access or contribute to and how this information may be used. If you require
further details please contact us at:
Policy Investigation Unit, Aviva, Cruan Business Centre, Westerhill Business Park, 123 Westerhill Road, Bishopbriggs Glasgow G64 2QR.
Telephone: 0345 300 0597. Email: PIUUKDI@AVIVA.COM
We and other organisations may also search these agencies and databases to:
Help make decisions about the provision and administration of insurance, credit and related services for you and members of your household;
Trace debtors or beneficiaries, recover debt, prevent fraud and to manage your accounts or insurance policies;
Check your identity to prevent money laundering, unless you provide us with other satisfactory proof of identity.
Check details of job applicants and employees.
Claims History
Under the conditions of your policy you must tell us about any insurance related incidents (such as fire, water damage, theft or an accident) whether or not
they give rise to a claim. When you tell us about an incident we will pass information relating to it to a database.
We may search these databases when you apply for insurance, or in the event of any incident or claim to validate your claims history or that of any other
person or property likely to be involved in the policy or claim.
You should show these notices to anyone who has an interest in the insurance under the policy.
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If You Have a Complaint
We hope that you will be very happy with the service that we provide. However, if for any reason you are unhappy with it, we would like to hear from you.
In the first instance, seek resolution by contacting Aviva Tenants Contents Unit on telephone number 0345 0308 733. Aviva is covered by the Financial
Ombudsman Service. If you have complained to us and we have been unable to resolve your complaint, you may refer it to this independent body.
Following the complaints procedure does not affect your right to take legal action.
Choice of Law
The Law of England and Wales will apply to this contract unless:
1 You and the Insurer agree otherwise; or
2 At the date of the contract you are a resident of (or, in the case of a business, the registered office or principal place of business is situated in) Scotland,
Northern Ireland, Channel Islands or the Isle of Man, in which case (in the absence of agreement to the contrary) the law of that country will apply.
Important Notice - Information we need to know about
You must take reasonable care to provide complete and accurate answers to the questions we ask when you take out, make changes to, and renew your policy.
Please read any assumptions carefully and confirm if they apply to your circumstances.
Please tell your insurer if any of the information provided by you changes after you purchase your policy, or if there are any changes to the information set out
on your schedule. You must also tell the insurer about the following changes;
any change to the people, or to be insured
any change or addition to the contents or the property to be insured that results in the need to increase the amounts insured or the limits that are shown
on your policy schedule
if your property is to be lent, let, sub-let, or used for business purposes (other than occasional clerical work)
if your property is to be unoccupied for any continuous period exceeding 60 days, or
if any member of your household or any person to be insured on this policy is charged with, or convicted of a criminal offence (other than motoring offences).
If the information provided by you is not complete and accurate:
we may cancel your policy and refuse to pay any claim, or
we may not pay any claim in full, or
we may revise the premium, or
the extent of the cover may be affected
The Insurer recommends you keep a record (including copies of letters) of all information provided to the insurer for your future reference.
A copy of the completed application form will be supplied on request within a period of three months after its completion.
Please read the declaration below carefully before signing it
Declaration
I/We declare that the information given is to the best of my/our knowledge and belief correct and complete.
If the risk is accepted I/We undertake to pay the premium when called upon to do so.
I/We understand that my/our information may also be disclosed to regulatory bodies for the purposes of monitoring and/or enforcing the insurer’s
compliance with any regulatory rules/codes.
I/We have read the information provided under the heading “Important Information”.
You must ensure that your sum(s) insured are not less than the full cost of replacing the goods; failure to do so may invalidate your policy or reduce
claims settlements.
Joint applicants should both sign if policy is required in joint names.
Special note
If during the period of your insurance cover, your home is likely to be unoccupied (e.g through hospitalisation, extended holiday) for more than 60 days
in a row you will have to advise the Administrator.
Underwritten by Aviva Insurance Limited. Registered in Scotland No.2116. Registered Office: Pitheavlis, Perth PH2 0NH
Aviva Regulatory Status
We are authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.
We are registered as: Aviva Insurance Limited and our firms reference number is 202153.
You may check this information and obtain further information about how the Financial Conduct Authority protects you by visiting their website
www.fca.org.uk or by contacting them on 0800 111 6768.
TD7745k-11/17
Applicants name Applicants signature Date
DDM M Y Y YY
Signature not required if submitting electronically
Joint proposer name Joint proposer signature Date
DDM M Y Y YY
Signature not required if submitting electronically
Please save or print a copy of the completed form for your records. Click the submit form button to return the completed form.
Please Note: If you are submitting this form via an internet mailbox such as Hotmail or Yahoo you need to save a copy of the completed form to your desktop,
open your mailbox and send the form as an attachment to: housingincome@norwich.gov.uk with subject line Completed Proposal Form.
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