RESIDENTIAL LANDLORD EMERGENCY ASSISTANCE

STATEMENT OF FACT

The information you have supplied to us is used to determine whether we will accept your insurance quotation, and if so, the premium to be charged and the terms, conditions and exclusions to be applied. You must ensure to the best of your knowledge and belief that all the information you provide to us is correct and accurate. Failure to disclose correct and accurate information may result in your insurer refusing to pay claims and/or void this insurance.

POLICY NO:

INSURED:

CORRESPONDENCE ADDRESS:

INSURED ADDRESS:

PERIOD OF INSURANCE:

Both days inclusive, local standard time, at the address of the Insured

I confirm that I:

DECLARATION

I declare that to the best of my knowledge all of the information provided in connection with this Statement of Fact is correct and complete. I agree that this policy is for insurance in the normal terms and conditions of the Insurers and forms the terms of the contract between me and Legal Protection Group.