This form is designed to provide sufficient information to evaluate your particular circumstances and enable us to arrive at a price for the cover you have chosen. Please be thorough in the completion of this form. The more information we have the easier it is for us to set a premium that is right for you and your needs.

In addition, please be aware of the following points:

• Answer all questions to the best of your knowledge and belief.
• Please give us all the information you can, particularly where the information may be regarded as a "material fact". A "material fact" is information that may influence the way we deal with this proposal. If you are in any doubt as to what constitutes a material fact, you should consult your advisor, or contact us on 0208 315 5000
• If you think that any question requires expert knowledge, whigh you are unable to provide, please consult the appropriate expert and indicate this in your answer.
• We recommend that you keep a copy of this form and any other documents you send to us in support of your proposal.