Your Personal Details:
Title
Mr
Mrs
Miss
Ms
Other
Forenames
Surname
Address
Post Code
Home Phone Number
Fax Number
Work Phone Number
Email Address
Date of Birth
Occupation
About Your Home
Accommodation
Owner Occupied
Tenant
Other
Unoccupied during the day
Yes
No
House Type
eg - detatched
Construction
Standard
Other
If other, please give details
Year Built
Number of Bedrooms
Years Free Claim
Neighbourhood Watch
Yes
No
5 lever Mortice Deadlocks on all exterior doors
Yes
No
Alarm
Yes
No
Is the Alarm NACOSS Approved?
Yes
No
Smoke Alarm
Yes
No
Buildings
Accidental Damage
Yes
No
Sum Insured
Present Insurer
Claims Last Three Years
Yes
No
If Yes, please give details
Contents
Accidental Damage
Yes
No
Sum Insured
Present Insurer
Claims Last Three Years
Yes
No
If Yes, please give details
Maximum Value of Any One Item
All Risks This
is for items taken outside the home.
eg, videocameras.
The
following six items are optional extras.
Note:
some policies will automatically include
some of these options as standard.
Personal Effects
Details and values of any individual items worth
more than £500
Valuables
Credit Cards
Money
Freezer Contents Value
Legal Expenses
Yes
No
If you have already been given a quote, please
enter the figure here
Which insurer was this quote from?
Please give the renewal date of your existing policy
or the commencement date of the new
policy
Contact Method
How would you like us to contact you?
By
Phone
