Title: *

First Name: *

Last Name: *

Occupation:

Age: *

Property to Insure Address Postcode: *

Property to Insure Address:

How do you wish us to contact you?

Contact Telephone: *

Mobile Number:

Fax Number:

Email Address: *

Date Cover to Start (dd/mm/yy):

Buildings sum insured:

Buildings accidental damage?

Contents sum insured:

Contents accidental damage?

Have there been any losses/claims in the last 5 years?

If yes, please give brief details:

Have you had any previous convictions?

Who is/was your previous insurer?

Have you ever been refused cover or had any additional terms applied?

Target Premium?

Is the property, a holiday/second home?

If no, please give a description of use:

Is the property any of the following:

Construction type? (Please specify full details i.e. floor type, roof type, wall type, etc.)

If timber construction, is there any wood-burning stoves or open fires?

If timber construction, when was the last electrical inspection?

What percentage of the roof is flat?

Is Property Listed?

Age of Building: *

Is the property in a good state of repair?

Does the client have a survey report?(Only for pre 1980 and £500k or over.)

Is the property let via an agent?

Is the property fitted with 5 lever mortice dead locks on the final exit doors?

Does the property have key operated window locks on all accessible windows?

Does the property have internally lockable wooden shutters?

Does the property have metal grilles embedded into the walls?

Please specify any other security features the property has:

Has the property/area had a history of storm, flood, subsidence, landslip or heave?

Are there trees within potential influencing distance of the property?(over 3m tall within 3m of the nearest building.)

If Yes, please specify the distance from the property, type, height and spread of tree:

Additional Information: