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Policyholder Details

Title First Name Surname

Number Street Town

County Post Code

Home Tel Work Tel Fax No

E-Mail

How would you like to be notified of your quote?

Date cover is required from

Date of birth Marital Status

Smoker First Time Buyer

Occupation (Bricklayer) Business (Building Trade)

Employment Status

Claims

Have you made any claims on this or any other property in the last 5 years

If yes, complete the form below with the most recent claims first:

	Claim 1	Claim 2	Claim 3
Date of claim
Type of claim
Please provide full details of claim (i.e. Fire, Theft, etc.)
Was claim at the property to be insured
Cost of claim (estimate if not sure)

Property Details

Type of property

Date you became resident

Year the property was built Number of Bedrooms

Wall Construction Roof Construction

Percentage of Total Roof which is flat

How many people occupy the house How many of these are under 18

Ownership type

Occupancy Status Listed Building

Has your home been extended, other than for a conservatory, which has resulted in more than a 10% increase in the original floor area?

Is the home occupied solely by you and your family

Is it used for any business purposes

Is the home self-contained with separate lockable entrance under your control

Is the property unoccupied: During The Day During The Night

What is the maximum number of consecutive days the property is left unoccupied

Do you have an approved burglar alarm fitted

If yes, please provide full details of alarm (i.e. NACOSS, audible only, etc)

Do you have approved locks fitted (i.e. 5 lever mortice)

Do the premises have exterior security lighting?

Are the security devices activated at night or when the property is unoccupied?

Do you agree to always use such devices for a possible premium discount

Are you a member of an approved Neighbourhood Watch scheme

Are there any smoke detectors

Is there a safe at your property

Is the property in a position/area likely to be subject to flooding or where flooding has occurred, close to a cliff, quarry or other excavation, or shows any signs of existing of previous damage by subsidence, ground heave or land slip

If Yes, please give full details

Cover

Please complete one or both of the following two sections (i.e. Buildings Only, Contents only or Buildings and Contents)

Contents Sum Insured (if required)

Is accidental damage required

Number of claim free years earned on Contents Insurance

Value of the most expensive item kept in the home

Do you require cover on contents outside the home

If yes, what sum insured is required for them

Please list all items over £1000 and their individual values

Buildings

Buildings Sum Insured (if required)

Is accidental damage required

Number of claim free years earned on Buildings Insurance

Final Questions

Have you been convicted of, or in the course of being charged with, any offence (excluding driving offences)

Have you been declared bankrupt or been a director of any company that went into liquidation

Have you had any insurance declined, cancelled, refused or had any special terms applied by any Insurer for the risks proposed

If you have answered "Yes" to any of the three questions above, please provide full details in the additional information section below.

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Please add any additional information that may be required for your quotation in the space below

Thank you for taking time to fill out this form. Please ensure that all required details have been completed (you will be prompted to complete the sections you have missed) and double check that your e-mail address is correct if this is your chosen method of reply or we may not be able to return your quote. Please then press the submit button below to send your details to us, wait for the confirmation page to load and you will then be contacted with your quotation as soon as it is processed.