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How to register – payment method By cheque or credit card

I wish to pay the sum of

£

by cheque/credit card (delete as appropriate)

Payment by cheque

Please make this payable to ‘Zurich Insurance’ and return with this completed form to the address below.

Payment by credit card Please debit my Mastercard/Visa account (delete as applicable)

Cardholder’s name

Cardholder’s address

Postcode

Card number

5 4

Expiry date

Signature

Date

Proposal declaration

This is in respect of the construction of a single private dwelling for my/our occupation to be built to comply with the Technical Requirements of Zurich Insurance Building Guarantee with skilled work carried out by professional subcontractors/tradesmen.

I understand that I must occupy the property for a minimum of 3 months following the issue of the Insurance Certificate and that new applications under the Zurich selfbuild scheme will not be considered until two years have elapsed from the date of issue of the Insurance Certificate.

I have read and understood the terms of the proposal and I understand that the information given by me will form the basis of a contract of insurance and that any misrepresentation or non-disclosure of a material fact may invalidate the policy. I enclose my registration fee and all other required information.

Signature

Date

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