Please give your:
Surname:
First Name:
Occupation:
Date of birth:
Address:
Postcode:
Email:
Tel:
Mob:
There is no need for you to complete the rest of this form if your enquiry is of a general nature
and one of our technicians will get back to you.
Alternatively continue and we wll get back to you with a premium indication for you to consider.
Home Insurance:
Previous
Insurer:
Date from which
cover is required:
Address of property, if different
from above
Please indicate type of property
House - Detached
House - Semi-Detached
House - Terraced
Bungalow - Detached
Bungalow - Semi-Detached
Flat/Masionette
Year of construction:
Number of bedrooms:
Is the property Standard construction
Ie: Brick/Stone and Tile/ Slate:
Yes
No (Provide details)
Details:
Is the home used as a private
residence only:
Yes
No (Provide details)
Details:
Is the Property Self Contained:
Yes
No (Provide details)
Details:
Is the property in good state of repair:
Yes
No (Provide details)
Details:
Does the home have 5 lever mortice deadlocks fitted to all entrance / exit doors:
Yes
No (Provide details)
Details:
Does the home have key operated window locks:
Yes
No (Provide details)
Details:
Does the property have NSI / NACOSS / SSAIB Alarm
Yes (Provide details)
No
Details:
Buildings Insurance (Only complete this section if you require buildings insurance)
Amount to be insured:
(This should be the full cost of rebuilding)
Contents Insurance (Only Complete this section if you require contents insurace)
Amount to be insured:
(This should be the full replacement cost)
Personal Belongings (Only complete this section if you require personal belonging insurance)
State the amount to be insured for clothing, items for
personal use normally worn or carried (including jewellery,
watches, musical instruments, photographic equipment,
mobile telephones, contact lenses, sport equipment)
This amount should represent the MAXIMUM you are
likely to have with you outside your home at any
one time:
Please specify any individual item which exceeds £1,500 in value.
1.
2.
3.
4.
Claims History:
Have you made any claims in the past:
1 Year
2 years
3 Years
4 Years
5 Years
Details:
Please note that the above information will be used to obtain an indication of the premium required. It may be nessecary to
obtain further details in order to confirm the premium and any conditions applying to the cov
er:
