Buildings & Contents Insurance Quotation Request

Information Capture Sheet

1. FIRST APPLICANT'S DETAILS
Name * Title First Last Suffix
Date of Birth * / DD / MM YYYY
Correspondence Address *
Street Address

Address Line 2

Town / City

County

Post Code

Country
Contact Telephone Number *

Please enter number only without spaces
Email Address *
Occupation *
Nature of Business *
2. SECOND APPLICANT'S DETAILS
Name (If there is a second applicant this must be completed) Title First Last Suffix
Date of Birth (If there is a second applicant this must be completed) / DD / MM YYYY
Contact Telephone number (If there is a second applicant this must be completed)
Occupation (If there is a second applicant this must be completed)
Nature of Business (If there is a second applicant this must be completed)
3. OTHER RESIDENTS Please give details of all other persons aged over 18 residing at the insured property (other than the applicants). This section must be completed if applicable.
Name(s), Date(s) of Birth, Occupation(s), Relationship to Applicants.
Number of Minors (those aged under 18) residing at the insured property.
4. DECLARATIONS ABOUT YOU AND YOUR HOME. Please read the following statements carefully and answer all questions.
Is the home occupied by someone other than the applicant(s) and their relatives, or occupied in whole or part by tennants or paying guests? *
Have the applicant(s) or someone living in the home been convicted of, or received a policy caution for any criminal offence (other than motoring offences)? *
Has the applicant(s) or someone living in the home previously had an insurance policy cancelled, been refused insurance or had special terms imposed? *
Is the home (including any garages or outbuildings) used for business purposes and/or are there callers to the property in connection with the applicant(s) business or profession? *
Are the applicant(s) or someone living in the home engaged in the entertainment business? *
Have the applicant(s) or someone living in the home been declared bankrupt? *
Do the Applicant(s) or someone living in the home smoke? *
PROPERTY OWNERSHIP
If property is owned is it: *
If you answered "On a Mortgage" on the above question the following 3 questions must be answered.
Mortgage Lender
Mortgage Lender's Address
Mortgage Roll Number/Account Number
5. INSURED ADDRESS If the insured address is different to the correspondence address, please enter it below including full post code. (If insured address has been lived at for less than 12 months please note previous address in additional notes section).
PROPERTY DESCRIPTION *
Number of Bedrooms *
Year Home Was Built? *
Declarations about you and your home. Please read the following carefully and answer all questions.
Does the home have a non standard construction (i.e. the external walls are not built of brick, stone or concrete, or less than 80% of the home is not roofed with slate, clay or concrete tiles, concrete or metal)? *
Is the property solely built of stone? *
Has the property had asbestos used in it's construction? *
Is the home (including garage) in a bad state of repair or not maintained? *
Is the home self contained (i.e. it has a seperate and private entrance under your sole control)? *
Will the home be lived in from commencement date of this insurance or completion of purchase? *
Is the home (including garage) in a locality where there is evidence (or a history) of subsidence, heave, landslip or flooding? *
Is the home your main residence? *
If you answered "no" to the above, please give details.
Is the home (including garage) situated less than 1/4 mile (400m) from the nearest river, watercourse or sea? *
Is the home (including garage) currently undergoing renovation or construction work? *
Is the home is a listed building? *
Is the home is normally unoccupied throughout the day? *
Is the home is normally unoccupied outside normal working hours? *
Is the home fitted with smoke detectors? *
Does the home have gas central heating? *
6. BUILDINGS INSURANCE
Buildings Sum Insured * £ . Pounds Pence
Type of Cover *
Excess *
Date of Purchase * / DD / MM YYYY
Date of Occupancy * / DD / MM YYYY
Claim Free Years *
7.CONTENTS INSURANCE
Contents Sum Insured * £ . Pounds Pence
Type of Cover *
Excess *
Claim Free Years *
Amount of valuables included within Contents Sum Insured £ . Pounds Pence
Details of valuables worth over £1000 Please give description & value of each item. *
Is the final exit door secured by a deadlock, all other external doors either secured by a deadlock or fitted top and bottom with key operated security bolts, and accessible windows fitted with key operated window locks? *
Is your home protected by an intruder alarm system installed and maintained by a NACOSS (National Approval Council for Security Systems) recognised firm? *
If you answered "yes" to the above question please enter the name of burglar alarm installation company.
If you answered the above question please enter the name of the burglar alarm maintenance company?
Are you a member of a policy approved Neighbourhood Watch Scheme? *
Are there any protections installed at the insured property? *
If yes, please provide details
8. PERSONAL POSSESSIONS COVER
Unspecified Personal Possessions Sum Insured. £ . Pounds Pence
Details of Specified Personal Possessions, please enter full description & value for each item.
Details of Pedal Cycles & Accessories
Please enter manufacturers name, model number & value for each item.
9. INSURANCE HISTORY
Have you held insurance before? *
If Yes, please enter Previous Insurer & Policy Number.
Claims History Please enter details of all previous claims including date, type of claim, amount & details.
What date would you like your cove to commence? * / DD / MM YYYY
10. OPTIONAL EXTRAS Family Legal Protection Garden Cover
Additional Notes

Buildings & Contents Insurance Quotation Request

Buildings & Contents Insurance Quotation Request

1. FIRST APPLICANT'S DETAILS

2. SECOND APPLICANT'S DETAILS

3. OTHER RESIDENTS Please give details of all other persons aged over 18 residing at the insured property (other than the applicants). This section must be completed if applicable.

4. DECLARATIONS ABOUT YOU AND YOUR HOME. Please read the following statements carefully and answer all questions.

PROPERTY OWNERSHIP

If you answered "On a Mortgage" on the above question the following 3 questions must be answered.

5. INSURED ADDRESS If the insured address is different to the correspondence address, please enter it below including full post code. (If insured address has been lived at for less than 12 months please note previous address in additional notes section).

Declarations about you and your home. Please read the following carefully and answer all questions.

6. BUILDINGS INSURANCE

7.CONTENTS INSURANCE

8. PERSONAL POSSESSIONS COVER

Details of Pedal Cycles & Accessories

9. INSURANCE HISTORY