Apply by Post

Untitled Document

homeworkers - application form

Please complete this application form and return it to Pavey Group (FREEPOST) at the appropriate address
(see end of page)

Section 1.

Full Name:

..............................................................

Trading as:

..............................................................

Address:

..............................................................

Postcode:

..............................................................

Telephone:

..............................................................

Email:

..............................................................

Full Business Description and Activities of the Business:

....................................................

Date cover to commence:

......./...... /.......

Is the home in which your office is situated:

Yes

Occupied solely by you and your family as an office and private dwelling?

Built of brick, stone or concrete walls with a slate, tile, asbestos, metal or concrete roof, including any outbuildings/garages not attached to the main building if any part of your business is operated from there or any property relating to the Business is stored within?

In a good state of repair?

Regularly attended by day and night?

If a flat is it self-contained with its own lockable entrance?

Section 2.

Have you ever been refused insurance, or had any special terms or conditions imposed by any insurers?

(i) Is your office on the ground floor or below?

(ii) Is it an area which has in the past been flooded?

Have you sustained any loss or had any claim made against you whether insured or otherwise in respect of any of the insurance required at this or any previously occupied home/office during the past 3 years?

Have you ever been convicted or is any prosecution pending for any offence involving dishonesty of any kind (e.g. fire, fraud, theft or the handling of stolen goods)?

Have you or any company in which you have had an interest been declared bankrupt, or subject of bankruptcy proceedings, or made any arrangements with creditors?

Have you any court judgements or arrangements with creditors outstanding?

Are you at present insured, or have you ever proposed for insurance in respect of any of the covers to which this proposal applies?

Please give details of any questions answered in teh shaded boxes below:

Section 3.

Please state scale of cover required (1-4):
(See table below)

...............

Office Scale	Sum Insured	Premium
1	£5,000	£110.00
2	£10,000	£155.00
3	£15,000	£200.00
4	£20,000	£250.00

Section 4

Yes No

Do you require any of the following optional extra covers?

Products Liability

Legal Expenses

Contract Disputes

Statutory License Protection

Debt Recovery

5) If Products Liability cover is required please answer the following supplementary questions:

Do you, or to the best of your knowledge, any of your customers, export or sell or supply your products to the USA or Canada?

Does your business include distribution or retailing of any goods?

If yes:

(i)

Do you repackage or alter the labelling of goods in any way?

(ii)

Are any of the goods packaged or labelled with your branding?

Important
Before signing the declaration below, please ensure that all questions have been answered. You are reminded that you must disclose all material facts likely to influence the acceptance and assessment of the proposal. Failure to do so may render the insurance voidable. If there is any doubt whether facts might be considered material, these should be disclosed. No insurance is in force until the proposal has been accepted by the Company. The Company reserves the right to decline any proposal.

Declaration
I/We declare that:

(i)

the security at my/our home complies with the requirements as stated in the security details as laid out at the end of this document (if applicable) for the Postcode in which it is situated.

(ii)

to the best of my/our knowledge and belief, the answers given are true and that all material facts have been disclosed.

(ii)

this proposal and declaration shall be the basis of the contract between me/us and Fortis Insurance Company Limited and I/we will accept a policy on the standard form issued by the Company and be bound by the terms and conditions thereof.

(iii)

if any answer has been submitted by any other person, such person shall for that purpose be regarded as my/our agent and not the agent of the insurer.

Proposer Signature:......................................................................

Date:...........................................................................................

I enclose my cheque payment for £.................. (made payable to Pavey Group) or, please debit my credit card for a total of £...................

Card No:

Expiry Date:.................................................................................

Signed:...................................................... Date:.........................

Please return to:

followed by an appropriate address:

Pavey Group

FREEPOST (TA601)

Torquay

Devon

TQ1 3BR

Security

In the following postcode areas you must comply with the following level of security:

The final exit door must be fitted with a 5 lever mortice deadlock conforming to British Standard 3621 or rim deadlock (not to be confused with a nightlatch).
All other external doors not having 5 lever mortice deadlock must be fitted with mortice rack bolts at the top and bottom of the door in addition to a 2 or 3 lever mortice deadlock.
All windows or skylights accessible from the ground, adjoining roofs, porches or downpipes, must be fitted with key operated window locks.
The glass in louvre windows must be firmly fixed with 'superglue' or similar.
French doors must be fitted with a security keylock in addition to the lock fitted by the manufacturer.

Postcodes:
B13-17, 23-38, 40, 42-48, 65-74, 78, 90-95, BB1-6, 8-12, BD1-22, BH8, 13-16, BL0-9, BN1-3, 11-12, 14, 21, BR1-8, BS1-16, CA1-2, CF1-3, 5-6, 8, 34, 40-42, 44, 46-48, 61-64, 81-83, CH1, CM17-18, 20, CR0, 2-9, CT5, 9,11, CV1-7, 10-11, CW1, DA2-18, DE1-3, DH4-5, DL1-2, DN1-2, 4-8, 11-12, 17, 31-33, 35, DY1, 3-5, E4, E18, EH1-8, 11, 13-17, 54, EN1-11, FY1-4, G11-15, 20-23, 31-34, 40-46, 52-53, 60-62, 64, 69, 71-78, 81, 83-84, GL1, HA0-9, HD1-2, 4-6, HU1-9, HX1-7, IG1-11, KT1-2, 4, 6-9, 16, 19, L22-23, 28-31, 34-35, 37-40, 43, 45-49, 60-66, LE1-5, LS1-20, 23, 25-29, LU1-5, M10, 24-35, 38, 40-46, 90, ME1-3, 10-12, 15, 17-18, MK1, 4-6, 8-15, ML1-9, N20-22, NE9-13, 15-17, 20-41, 43, NG1-6, 8, NN1-5, 18, NP2, 9, OL1-16, PA1-5, 9,11, 14-15, PE1, PO1-2, PR1-3, 5-9, RG2, RM1-20, S1-14, 19, 31, 60-66, 70-75, SA1-2, 4-7, SK1-10, 14-16, SL0-4, SM1-7, SR1-8, SS1-2, 8, 13,-17, ST1-6, SW13-20, TN14-16, TS1-8, 10, 15, 17-21, 23-27, TW1-20, UB2-11, W3-8, 12-14, WA1-5, 7-16, WD1, 3-4, 6-7, WF2-3, 7-13, 15-17, WN1-8, WS1-6, 9-10, WV1-6, 9-14, YO1,3.

In addition, homes in the following areas must have an alarm system approved by NACOSS, with a maintenance contract.

B1-12, 18-21, E1-3, 5-17, EC1-4, G1-5, 51, L1-21, 24-27, 32-33, 36, 41-42, 44, M1-9, 11-23, N1-19, NE1-8, NW1-11, SE1-28, SW1-12, UB1, W1-2, 9-11, WC1-2.

Pavey Group is a trading style of Michael Pavey Ltd which is authorised and regulated by the Financial Services Authority. It's FSA registration no. is 308106. Pavey Group is also a trading style of Michael Pavey Financial Services Limited which is authorised and regulated by the Financial Services Authority. It's FSA registration number is 463257. You can check this on the FSA's Register, by visiting the FSA's website on www.fsa.gov.uk/register or by contacting the FSA on 0845 606 1234.

Michael Pavey Ltd. (Registered in England 3419086) and Michael Pavey Financial Services Ltd (Registered in England No. 3418320) are subsidiary companies of Michael Pavey Holdings Ltd (Registered in England No. 02979493). Our registered Address: 50 The Terrace, Torquay, Devon, TQ1 1DD.

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