Home contents insurance scheme Home contents insurance scheme Application formDo you want to take out content insurance?(Required) Yes No Unfortunately we are unable to proceed with you application online. This does not automatically mean that you cannot join the scheme. Please call 01462 534 003 to discuss application further. Your full nameFull name(Required)Date of birth(Required) MM slash DD slash YYYY Email address(Required) Phone number(Required)Is the policy required in joint names?(Required) Yes No Your domestic partnerFull nameDate of birth MM slash DD slash YYYY Address Street Address Address Line 2 City County Post code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Are you a Tenant of Settle?(Required) Yes No Are you a Leaseholder of Settle?(Required) Yes No Required start date DD slash MM slash YYYY Must be a Monday The amount of insurance requiredEnter the amount of insurance required in multiples of 1,000 (e.g., 4,000, 5,000, 10,000, etc.).See cost of insurance values page for more information.Do you require accidental cover?(Required) Yes No Do you require personal belongings cover?(Required) Yes No Please confirm the amount your personal belongings cover will cost? £1,000 £2,000 £3,000 £4,000 Do you require mobility scooter/wheelchair cover?(Required) Yes No Please confirm the amount your scooter/wheelchair cover will cost? £1,000 £2,000 £3,000 £4,000 Do you require hearing aids cover?(Required) Yes No Please confirm the amount your hearing aids cover will cost? £1,000 £2,000 £3,000 £4,000 Is your home self contained with its own separate lockable front door?(Required) Yes No Is this property your permanent home and occupied only by yourself and members of your immediate family normally living with you?(Required) Yes No Does the amount of insurance you have chosen cover the full cost of replacing all your household goods and personal belongings?(Required) Yes No If you have answered no, to any of the above questions, please give more details below:Do you regularly leave your home empty or unattended for more than 60 days?(Required) Yes No Is your home used for running a business?(Required) Yes No Have you or anyone living with you ever been refused insurance, had insurance cancelled or had special terms imposed by an insurer?(Required) Yes No If you have answered yes, to any of the above questions, please give more details below: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?(Required) Yes No If you have answered yes, to any of the above questions, please give more details below:Date of incident DD slash MM slash YYYY What caused the loss ?E.g. theft, water damage etc. Value of goods lost or damagedWere you insured at the time? Yes No If so, how much did the insurers pay in settlement of the claim?If you have had a burglary in the last five years please state(Required) Yes No How entry was gained?What additional security has been installed since the incident?E.g. extra locks, alarms etc 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?(Required) Yes No Date of conviction or charge DD slash MM slash YYYY Nature of offencePenalty receivedAmount of fine, length of sentence etc. Your age at the timeFor additional informationDeclaration(Required) 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 insuer’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. Your Name(Required) First Last Date of form submission(Required) DD slash MM slash YYYY Consent(Required) I agree to the Privacy policySee the Privacy policy page for more information.Aviva Regulatory StatusWe 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 6768EmailThis field is for validation purposes and should be left unchanged. Δ
