Main Proposer's Details
Title
...Choose... Mr Miss Mrs Mrs Dr
Sex
...Choose... Male Female
First
Name
Last
Name
Your Full
Address
Address of Building to be Insured if different from above
Post
Code
Home
Telephone
Best Time of
Contact
Work
Telephone
Work Fax
Number
Mobile
Telephone No.
E-mail
Address
Date Of
Birth
Employment
Status Employed Self Employed Part Time Unemployed House Wife / Husband In Full / Part Time
Education Unemployed Due To
Disability Retired Voluntary Work
Employers
Business
1st Time Home
Buyer ...Choose... Yes No
Spouse or Partner's Details
Title ...Choose...
Mr Miss Mrs Mrs Dr
First Name
Last
Name
Date Of
Birth
Employment
Status Employed Self
Employed Part Time Unemployed House Wife / Husband In Full / Part Time
Education Unemployed Due To
Disability Retired Voluntary Work Not Applicable
Employers
Business
Present or Previous Cover Details Contents Cover:
Present /
Previous Cover New For Old
Accidental Damage None
Present /
Previous Insurer
Renewal Or
Commencement Date
Renewal
Premium £
Current Excess
£
Number Of Claim Free Years
0 1 2 3 4
5 6 7 8 9
10 11 12 13 14 15 Other
Buildings Cover:
Present /
Previous Cover Reinstatement
Accidental Damage None
Present /
Previous Insurer
Sum Insured
£
Renewal Or
Commencement Date
Renewal
Premium £
Current Excess
£
Number Of Claim Free Years
0 1
2 3 4 5 6
7 8 9 Max
Property to be Insured
Full Postcode
Of Property to be Insured
Residence ...Choose... Main Sole Occupants Unoccupied Business Use Holiday Home Paying Guests Part Let to Tennants
Accommodation
Mortgaged Owner Occupied Rented - Unfurnished Rented - Furnished
Letting
Status Not Let Let
Let Furnished Let Unfurnished
Letting Type if applicable
...Choose...
Not Applicable Mortgaged - Let Furnished
Mortgage - Let
Unfurnished Mortgaged - Not
Let Mortgaged - Sometimes Let
Furnished Mortgage -
Let Unfurnished Owned -
Let Furnished Owned - Not
let Owned -
Sometimes Let Furnished Owned - Sometimes Let
Unfurnished Rented (Local Authority) -
Furnished Rented (Local Authority)
- Unfurnished
Total Number of Occupants over the Age of 18
years
Total Number of Occupants Under the Age of 18
years
Any Business
Use in your Residence ...Choose... None Clerical
Use Full Partial Business Use
Any Business
Stock Kept in your Residence
Any Business
Equipment in your Residence
Approximate
Year Property Built
'House'
Type Mansion Detached House Semi - Detached House End Terraced House Mid Terraced House Maisonette Semi Detached Maisonette
Mid Terraced Maisonette
End Terraced Maisonette
Bungalow Detatched Bungalow Semi Detatched
Has the
Property been Surveyed ...Choose... RICS/FSVA Survey Structural Engineers Report
New House Build Gaurantee
'Flat'
Type Basement Flat
Conversion Basement
Purpose Built Flat Ground Floor Flat
Conversion Ground Floor Purpose Built
Flat Other Floor
Flat Conversion Other Floor Purpose Built
Flat Service Flat Within
Employers Premises Top Floor Flat Conversion
Top Floor Purpose Built
Flat
If a Flat, is
it...
...Choose... Self Contained Non Self Contained
'Other'
Type ...Choose... House Boat Mobile Home Static Caravan Other
Property
Construction
...Choose... Asbestos Brick
Brick and Timber Cob Concrete Corrugated Iron Essex Fibre
Glass Glass Metal Plastic
Prefab Stone
Timber Timber
Frame
Roof
Type ...Choose... Asbestos Concrete Corrugated Iron Felt Fibre
Glass Plastic Rigid Metal Shingle Slate
Thatched Tiled Timber Turnerised Woodwork
Number Of
Bedrooms
When is
Property Unoccupied ...Choose... Never Day Time
Night Time 30 Days 60 Days
+
Is It a
Holiday Home ...Choose... No Yes
Is the
property Free from Storm/Flood; Subsidence; Landslip; Ground
Heave
...Choose... No Yes
Is the
Property in Good Repair
...Choose... No
Yes
Is the
Property near a River or Quarry
...Choose... No
Yes
Is the
Building Listed
...Choose... No
Yes
Is your property
being repaired and Underpinned
...Choose... No
Yes
Security Measures Please
answer all questions in this section As
discounts on your Home + Contents Insurance can depend on this
information
Door Locks
Fitted to BS 3621 (5 Lever Mortice) Final Exit Door ...Choose...
Yes No
Door Locks
Fitted to BS 3621 (5 Lever Mortice) to Other Exit Door ...Choose...
Yes No
Patio Doors
Fitted with Security Locks ...Choose...
Yes No
Window
Security Locks Fitted ...Choose...
Yes No
Intruder /
Burglar Alarm Fitted ...Choose...
Yes No
Accredited
Burglar Alarm / Intruder System Fitted (i.e. NACOSS) ...Choose...
Yes No
Member of
Neighbourhood Watch Scheme ...Choose...
Yes No
Smoke Alarms
Fitted ...Choose...
Yes No
Claims
Have You Had
Any Claims In The Last 5 Years ...Choose... No - Go to next Section If Yes - Give details
below
Claims: Please give
dates; type of Loss and amount Claimed .
Convictions
Proposer and
anyone living in the residence ever declined insurance ...Choose... Yes No
Proposer and
anyone living in the residence ever been bankrupt ...Choose...
No If Yes - give details below
Proposer and
anyone living in the residence have any convictionsions or
Pending
INSURANCE COVER
REQUIRED
Buildings Insurance:
Type of
Buildings Insurance Required ...Choose... Not
Wanted Total Rebuild
Cost Total Rebuild Cost +
Accidental Damage
State if
Voluntary Excess Required £ ...Choose... £50 £100 £150 £200 £250 £300 £500 £1000
State Value of
Building to be Insured
Contents
Insurance:
Type of
Contents Insurance Required
...Choose... Not Wanted New
for Old
Total Value Of
Household Contents to be Insured
Total Value Of
Household Contents to be Insured
ALL RISKS INSURANCE
(If you
have chosen 'All Risks' option part of your
Contents Insurance
Unspecified
Items:
Unspecified
Valuables
Unspecified
Photographic Equipment
Unspecified
Sports Equipment
Unspecified
Money
Unspecified
Credit Cards
Unspecified
Freezer Contents Max. Age of
Freezer Contents
Unspecified
Furnishings
Unspecified
Clothing
Unspecified
Personal Effects
Unspecified Bicycles (State Number of Bicycles: Value: Make: and
Model
If you have
chosen 'All Risks' List Specified Items (Value of each item over £1000
Including V.A.T.)
Specified Item
with Value over £1000 incl. V.A.T )
Specified Item
with Value over £1000 incl. V.A.T)
Specified Item
with Value over £1000 incl. V.A.T)
Specified Item
with Value over £1000 incl. V.A.T)
Specified Item
with Value over £1000 incl. V.A.T)
Specified Item
with Value over £1000 incl. V.A.T)
Specified Item
with Value over £1000 incl. V.A.T)
Caravan Details
(give details if applicable):
Caravan Use
...Choose... Touring Use Let For Hire or Reward
Type
Make
At Risk Address When Unused
Always Kept on
a fixed Site ...Choose...
Yes No
Serial Number
Chassis or Vin
Number
Date Purchased
Price Paid
Caravan
Contents and Personal Effects
Caravan
Contents Audio / Visual
Boat /
Small Craft Detail (give details if
applicable):
Type
Name
Sail
Number
Class
Model /
Make Date of
Manufacture
Engine Details
( Type)
Engine Details
(Make)
Engine Details
(Serial Number)
Engine Details (Horse Power)
Engine Details (Date of Manufacture)
Maximum Speed of Boat / Craft
Is the Boat / Craft over 5 mtrs (or 16 ft 6 inches)
Do you want Insurance Cover for Boat / Craft + General
Items
...Choose... Yes No
Do you want Insurance Cover for Outboard Motor
...Choose... Yes No
Do you want Insurance Cover for Road Trailer
...Choose... Yes No
Do you want Insurance Cover for Launching Trolley
...Choose... Yes No
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