First name:
Last name:
Date of birth:
Email:
House name/number and street:
Town:
City :
Post Code:
Is this the address at which insurance is required?
Employment status:
Occupation:
Property type:
Property format:
Number of bedrooms:
Number of claims in last 5 years:
Date of most recent claim:
Value of claims in past 5 years:
Property occupancy status:
Is the property to be insured built of Brick or stone with a pitched tiled or slated roof? :
If yes to the above please give further details :
% flat roof :
When was flat roof last re-covered?
Does the property have any outbuildings other than garages, domestic sheds or greenhouses, or summer houses?
Is the property to be insured in a good state of repair with a self contained entrance, in an area free of any history of flood, or subsidence, heave or landslip, and free of any defect to the best of your knowledge and belief?
If No to the above please give further details :
Is the property fitted with Smoke alarms?
Is the property in a Neighbourhood Watch Area?
Do you wish to claim a security discount? PLEASE READ REQUIREMENTS CAREFULLY
Total No of occupants :
No. of occupants under 18 years of age :
Are any of the occupants smokers?
Is any part of the property occupied by anyone other than your immediate family?
If Yes to the above please give further details :
Is any part of the property used for business purposes?
Is the use purely clerical?
Value of office equipment :
Value of Stock :
Do people ever visit your property in connection with your business?
Buildings amount insured required :
Cover Required :
Contents amount insured :
Cover required :
Worldwide cover for Personal possessions :
Cycles (please list each one) :
Specified items of jewellery and personal possessions eg. Any item or set individually valued at more than £1,500.00 :
Are you interested in adding annual Travel insurance?
