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1
(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, Income Section, Town Hall, Alcester Street, Redditch, Worcestershire, B98 8AH.
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 Redditch Borough 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
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.
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
Redditch Borough 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.
Do you require Personal Belongings cover?* Yes No If yes, tick sum insured required £1,000 £2,000 £3,000
2
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
3
For additional information
Important Information
Data Protection – Privacy Notice
Personal Information
We collect and use personal information about you so that we can provide you with a policy that suits your insurance needs.This notice explains the most
important aspects of how we use your information but you can get more information about the terms we use and view our full privacy policy at
www.aviva.co.uk/privacypolicy or request a copy by writing to us at Aviva, Freepost, Mailing Exclusion Team, Unit 5, Wanlip Road Ind Est, Syston,
Leicester LE7 1PD.
The data controller responsible for this personal information is Aviva Insurance Limited as the insurer of the product. Additional controllers include the
Administrator and Aon UK Limited, who are responsible for the sale and distribution of the product, and any applicable insurers, reinsurers or brokers we use.
Personal information we collect and how we use it
We will use personal information collected from you and obtained from other sources:
• to provide you with insurance: we need this to decide if we can offer insurance to you and if so on what terms and also to administer your policy, handle
any claims and manage any renewal,
• to support legitimate interests that we have as a business.We need this to:
• manage arrangements we have with our insurers, reinsurers and brokers we use, and for the detection and prevention of fraud
• help us better understand our customers and improve our customer engagement. This includes profiling and customer analytics which allows us to make
certain predictions and assumptions about your interests, make correlations about our customers to improve our products and to suggest other products
which may be relevant or of interest to customers,
• to meet any applicable legal or regulatory obligations: we need this to meet compliance requirements with our regulators (e.g. Financial Conduct Authority),
to comply with law enforcement and to manage legal claims, and
• to carry out other activities that are in the public interest: for example we may need to use personal information to carry out anti-money laundering checks.
We may also use personal information about other people, for example family members you wish to insure on a policy. If you are providing information
about another person we expect you to ensure that they know you are doing so. You might find it helpful to show them this privacy notice.
The personal information we collect and use will include name, address and date of birth, financial information and details of your home. If a claim is made we
will also collect personal information about the claim from you and any relevant third parties. We may also need to ask for details relating to the health or any
unspent offences or criminal convictions of you or somebody else covered under your policy. We recognise that information about health and offences or
criminal convictions is particularly sensitive information.We’ll ensure that we only use that information where we need to for our insurance purposes (including
assessing the terms of your insurance contract, dealing with changes to your policy and/or dealing with claims).
There may be times when we need consent to use personal information for a specific reason. If this happens, we will make this clear to you at the time. If you
give us consent to using personal information, you are free to withdraw this at any time by contacting us – refer to the “Contacting us” details below. Please
note that if consent to use information is withdrawn we will not be able to continue to process the information you gave us for this/these purposes. This
would not affect our use of the information where consent is not required.
Of course, you don’t have to provide us with any personal information, but if you don’t provide the information we need we may not be able to proceed with
your application or any claim you make.
Some of the information we use as part of this application may be provided to us by a third party. This may include information already held about you and
your home within the Aviva group, including details from previous quotes and claims, information we obtain from publicly available records, our trusted third
parties and from industry databases, including fraud prevention agencies and databases.
Automated decision making
We may carry out automated decision making to decide whether we can provide insurance to you and on what terms, deal with claims or carry out fraud
checks. In particular we may use an automated underwriting engine to provide on-line quotes, using the information we have collected.
4
How we share your personal information with others
We may share your personal information:
• with the Aviva group, our agents and third parties who provide services to us, the Administrator and Aon UK Limited, and other insurers (either directly or via
those acting for the insurer such as loss adjusters or investigators) to help us administer our products and services,
• with regulatory bodies and law enforcement bodies, including the police, e.g. if we are required to do so to comply with a relevant legal or regulatory
obligation,
• with other organisations including insurers, public bodies and the police (either directly or using shared databases) for fraud prevention and detection
purposes,
• with reinsurers who provide reinsurance services to Aviva and for each other in respect of risks underwritten by Aviva, with insurers who cover Aviva under
its group insurance policies and with our brokers who arrange and manage such reinsurance and insurance arrangements.They will use your data to decide
whether to provide reinsurance and insurance cover, arrange and manage such cover, assess and deal with insurance and reinsurance claims under such
cover and to meet legal obligations.They will keep your data for the period necessary for these purposes and may need to disclose it to other companies
within their group, their agents and third party service providers, law enforcement and regulatory bodies.
Some of the organisations we share information with may be located outside of the European Economic Area (“EEA”). We’ll always take steps to ensure that
any transfer of information outside of the EEA is carefully managed to protect your privacy rights. For more information on this please see our Privacy Policy or
contact us.
How long we keep your personal information for
We maintain a retention policy to ensure we only keep personal information for as long as we reasonably need it for the purposes explained in this notice.We
need to keep information for the period necessary to administer your insurance and deal with claims and queries on your policy.We may also need to keep
information after our relationship with you has ended, for example to ensure we have an accurate record in the event of any complaints or challenges, carry
out relevant fraud checks, or where we are required to do so for legal, regulatory or tax purposes.
Your rights
You have various rights in relation to your personal information, including the right to request access to your personal information, correct any mistakes on our
records, erase or restrict records where they are no longer required, object to use of personal information based on legitimate business interests, including
profiling and marketing, ask not to be subject to automated decision making if the decision produces legal or other significant effects on you, and data
portability. For more details in relation to your rights, including how to exercise them, please see our full privacy policy or contact us – refer to the
“Contacting us” details below.
Contacting us
If you have any questions about how we use personal information, or if you want to exercise your rights stated above, please contact our Data Protection team
by either emailing them at dataprt@aviva.com or writing to the Data Protection Officer, Level 5, Pitheavlis, Perth PH2 0NH.
If you have a complaint or concern about how we use your personal information, please contact us in the first instance and we will attempt to resolve the issue
as soon as possible.You also have the right to lodge a complaint with the Information Commissioners Office at any time.
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, in the event of any incident or claim, or at time of renewal 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.
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.
5
Telephone call charges and recording
Calls to 0800 numbers from UK landlines and mobiles are free.The cost of calls to 03 prefixed numbers are charged at national call rates (charges may vary
dependent on your network provider) and are usually included in inclusive minute plans from landlines and mobiles. For our joint protection telephone calls may
be recorded and/or monitored.
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 firm’s 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.
TD8626-12/19
Applicants name Applicants signature Date
DD
M M Y Y YY
Signature not required if submitting electronically
Joint proposer name Joint proposer signature Date
DD
M 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: insurance@bromsgroveandredditch.gov.uk with subject line Completed Proposal Form.
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