Please take reasonable care to answer all the above questions accurately and completely. If you don’t, your policy may be cancelled, or treated as if it never existed, or your claim rejected or not fully paid.

About You

Your Personal Details:

You must be a UK Resident & the Property needs to be in the UK

Confirm
Cannot Confirm

Title

These should be the details of the main proposer, who must be the owner of the property and/or contents to be insured.

First Name

Surname

How would you like us to refer to you?

Date of Birth

Marital Status

Please enter the postcode of your correspondence address

This should be the postcode of your correspondence address.

Policy Address:

Address 1

Address 2

City

County

Contact Details:

Telephone Number

Please note we will only contact you regarding admininstration of your policy unless otherwise agreed by you.

Your email address:

Please enter your email address so that we can send you your quotation and documentation, and details of other offers if you have chosen this option.

Occupation: Please confirm that you or any other occupant do not work in any of the following industries: gambling, public eye, foreign & diplomatic service, or professional sports.

I Can Confirm
I Cannot Confirm

Would you like to add a joint policyholder?

To be a joint policyholder the person must either own the home you wish to insure and/or its contents jointly with you, or own part of the home you wish to insure and/or some of its contents.

Title

First Name

Surname

Date of Birth

Marital Status

What relationship is the Joint Proposer to you?

CCJs/IVAs:

Has any Policyholder ever had any IVAs, CCJs or been declared bankrupt?

How many IVAs or CCJs have been served?

When was the last one served?

If you have been declared bankrupt is the bankruptcy still in force

Was the bankruptcy Personal OR Commercial

Personal
Commercial

Please record further information about the CCJ/Bankruptcy

Convictions:

Have you or anyone living at the property been convicted of any criminal offence other than driving offences that remains unspent, or has any prosecutions pending?

What was the conviction for?

What was the date of the conviction?

Length of sentence from?

Length of sentence to?

Details of fines of community service?

Is there a prosecution pending?

Please record further information about the Convictions

Refused or had cover cancelled or voided:

In the last five years, have you or anyone living at the property been refused or had cover cancelled or voided for property insurance?

Please record further information about the Previous Insurance Refusal/Cancellation

Additional Information:

How did you hear about us?

I’m happy for Emerald Life to send me information about their products and services including discounts on further purchases?

Promotional Code - please enter if applicable

Key Benefits *

Up to £1,500,000 of home insurance and up to £150,000 of contents online. Call us on 0330 113 7109 for higher levels
FREE Legal & Home Emergency cover automatically included
Accommodation cover up to 24 months while your house is repaired
Optional accidental damage cover including damage by pets
Legal expense cover for any form of illegal discrimination

* for standard home & contents policies