CLIENT DETAILS
Client name *
Date of birth
Address line 1 *
Address line 2
Address line 3
Address line 4
Postcode
*
Occupation
Type of company
Telephone number *
Mobile telephone number
Email address *
PROPERTY DETAILS
Is the property your main residence and normally occupied?
>Please Select
>Yes
>No
Any lodgers, live in staff, tenants? >Please Select
>Yes
>No
If yes, give details
Is the property in a good state of repair? >Please Select
>Yes
>No
If no please give details
Year of construction?
How long have you lived at this address?
Property type (i.e. detached, terraced etc). Please specify which floor if a flat
Is the property of a standard construction? >Please Select
>Yes
>No
Do you have any Asbestos within the construction of your property including outbuildings? >Please Select
>Yes
>No
If no please give details
Listed or in a conservation area? >Please Select
>Yes
>No
If yes please give details
Is there any history of subsidence or flooding? >Please Select
>Yes
>No
If yes please give details
How far is the property from the nearest watercourse?
What height is the lowest part of the property above the nearest watercourse?
Have the gardens or grounds ever flooded, including run off of rainwater? >Please Select
>Yes
>No
If yes please give details
Are the premises used for any business purposes? >Please Select
>Yes
>No
If yes, please give details including any visitors and frequency, any stock and any employees at the premises
Are any building works planned in the next 12 months? >Please Select
>Yes
>No
If yes please give details
Please provide details of any trees or shrubs within seven metres of your home more than three metres tall (giving type, distance and height)
How is the property heated (eg. central heating, oil, log fire, log burner or other)?
Details of claims over the last 6 years
SECURITY
Do you have an alarm system? >None
>Audible
>Central Station
>Redcare
>Dual Com
Is the alarm maintained on an annual contract by a registered installer? >Please Select
>Yes
>No
Do you have auto firm alarm / smoke detectors fitted? >Please Select
>Yes
>No
Please give details
Do you have 5 lever mortice deadlocks fitted on all external doors?
>Please Select
>Yes
>No
If no please give details
Do you have key operated window locks on all accessible windows? >Please Select
>Yes
>No
If no please give details
Do all french / patio doors have key operated locks top and bottom? >Please Select
>Yes
>No
If no please give details
Do you have a safe installed? >Please Select
>Yes
>No
If yes please give details of make and model (floor or wall safe). Please also give details of any other notable security
SUMS INSURED
Buildings (main)
Outbuildings
General contents
Outdoor items
Fine Art Items
Paintings
Gold / silver / precious metals
Antique furniture
Clocks and barometers
Porcelain / glass
Books
Sculptures (non fragile)
Wine
Rugs and tapestries
Stamp collection
Coin collection
Other
Personal Possessions
Unspecified jewellery and watches
Specified jewellery and watches
Jewellery and watches kept in safe
Jewellery and watches kept in bank
Sports equipment
Guns
Pedal cycles
Furs
Other
Additional Details Current Insurer Renewal date Policy excess Current premium Have you or any permanent member of the household ever had any insurance declined, refused or special terms imposed? Or have any convictions apart from motoring offences? Ever been declared bankrupt or insolvent or have any pending County Court Judgements (CCJs)? >Please Select
>Yes
>No If yes please give details Please confirm that all material facts have been disclosed Additional information. Please provide any other information that might affect underwriters assessment of this risk
Security Code:
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