Subsidence questionnaire

If a structural survey or building society survey was carried out before or after the purchase of the property, you will need to supply a copy of the survey along with your application.

Any electronic copies of reports, plans or specifications you have which provide relevant information to the repairs to be carried out should also be attached.

If you only have paper copies of the above, please print out a copy of the subsidence form and send with copies of the surveys and reports to your contact at Ecclesiastical.

Ecclesiastical, Beaufort House, Brunswick Road, Gloucester GL1 1JZ

Address of property line 1

Address of property line 2

Address of property line 3

What is the age of the property’s extensions or additions?

Was a structural survey or building society survey carried out before or after purchase of the property?

YesNo

Are there any visible signs of damage to the property caused by foundation or other movement?

YesNo

Are there any visible signs of repair following such damage?

YesNo

Have the foundations and/or floor slabs ever required structural repair or underpinning at any time?

YesNo

Has the Local Authority made any special provisions regarding the design and construction of foundations and/or floor slabs at the property?

YesNo

Have there been any incidents of subsidence, heave or landslip at the property?

YesNo

Have there been any incidents of subsidence, heave or landslip in the neighbourhood?

YesNo

Is the property situated in the vicinity of railways, underground workings (actual or proposed) or watercourses?

YesNo

Is the property constructed on made-up ground or in-fill sites?

YesNo

Are there any trees within the grounds of the property of within 15m of the property?

YesNo

Have any trees been removed from within 15m of the property during the last three years?

YesNo

I declare that as far as I am aware the statements made by me or on my behalf in connection with this insurance are true and complete.

I agree to accept a policy and endorsement relevant to the issues addressed by this Questionnaire in the Company's usual form for this class of business.

Date

Day

Month

Year

Ecclesiastical Insurance Office plc. (EIO) Reg. No. 24869. Ecclesiastical Insurance Group plc. (EIG) Reg. No. 1718196. Ecclesiastical Life Ltd. (ELL) Reg. No. 243111. Ecclesiastical Group Asset Management Ltd. (EGAM) Reg. No. 2170213. Ecclesiastical Investment Management Services Ltd. (AIMS) Reg. No. 2170173. Allchurches Mortgage Company Ltd. (AMC) Reg. No. 1974218. Ecclesiastical Financial Advisory Services Ltd. (EFAS) Reg. No. 2046087. Ecclesiastical Risk Services Ltd (ERS) Reg. No. 6290300. All companies are registered in England at Beaufort House, Brunswick Road, Gloucester GL1 1JZ UK. Tel: 01452 528533. EIO, ELL, EGAM & AIMS are authorised and regulated by the Financial Services Authority and are members of the Financial Ombudsman Service. EIO & ELL are members of the Association of British Insurers and AIMS is a member of the Investment Management Association.

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subsidence questionnaire