Before progressing to the application form, please read the following questions carefully and ensure you provide your answers.

Please read the following assumptions we have made about you and your home and tell us if the assumptions we have made are correct to the best of your knowledge and belief:

• Your home is self-contained with its own separate lockable front door
• The property is your permanent home and occupied only by yourself and members of your immediate family living with you
• You do not regularly leave your home empty or unoccupied for more than 60 days
• Your home is not used for running a business
• You or anyone living with you has never been refused insurance, had insurance cancelled or had special terms imposed by an insurer
• You or anyone living with you has never been convicted or charged with any offence, other than motoring offences, or has any prosecution or police enquiry pending.

Your quotation and policy will be based on the above criteria and the answers to the questions in the application. Please select the relevant option below to continue.

Please note, if you have answered no to the above question we are unable to proceed with your application online. This doesn't automatically mean you cannot join the scheme, please call us on 0345 065 5656 to discuss your application further.

Claims history

Please note, if you have answered yes to the above question we are unable to proceed with your application online. This doesn't automatically mean you cannot join the scheme, please call us on 01642 771373 to discuss your application further.

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.

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.

Insurance starts when the administrator informs you that you have been accepted onto the scheme. 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. For further details please contact the administrator.

Please answer all the questions below in full. We can only consider your application once these questions have been answered.

Please give us the following information:

Important notice - Information we need to know about

You must take reasonable care to provide complete and accurate answers to the questions asked when you take out, make changes to, and renew your policy. Please read any assumptions carefully and confirm 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 you set out on your schedule. You must also tell the insurer about the following changes:

• Any change to the people, or to the 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 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
• 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:

• Aviva may cancel your policy and refuse to pay any claim
• They may not pay any claim in full
• They may revise the premium
• 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 this completed application form will be emailed to you once submitted.

Please read the declaration below carefully before checking the boxes/signing.

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 - reference number 202153.

You may check this information and obtain information about the Financial Conduct Authority protects you by visiting their website www.fca.org.uk or by contacting them on 0800 111 6768.