Please complete this form and we will endevour to get back to you as soon as possible.

 Personal Details
  Title   Forename   Surname
  I wish to be contacted by
  Street   Town/City
  County   Area
  Postcode   Tel
    Fax
    E-Mail
  Resident Type
  How long have you lived at the above address   Yrs
  DOB   Marital Status
    Employment Status
    Occupation
    Nature of Business
    StartOfCover dd/mm/yy
    Current Insurer
    Price to Beat
  How do you normally pay your premiums

  Home Insurance
  By not entering anything in the boxes below, we assume your answer is no.
  Has any member of your family or person living with you ever :
  a) Suffered loss or damage in respect of the events for which you wish to insure (whether a claim has been made or not)?
  b) Had an application of insurance declined, refused renewal of a policy, cover terminated, extra charges placed on top of the premium or special conditions imposed by an insurer?
  c) Been convicted, or charged but not yet tried, for any offence other than driving offences?
  In what year was your house built? :
  Is the home to be insured :
  a) Left for longer than 30 days or regularly unoccupied throughout the day or night? :
  b) Free from any sign of subsidence, heave or landslide? :
  c) The walls free from any cracks externally? :
  Are neighbouring homes free from signs of subsidence, landslides or have a history of damaging events? :
  Please give details if your home is a listed building :
  Is your property a :
  Is your home :
  a) Self contained and has its own lockable entrance door from street, hall or landing?
  b) Been furnished by yourself?
  Please give details on state of repair :
  Security Protection
  Do you have an alarm system installed with an annual agreement?
  If yes, give the name of the installing company and date of when the alarm was installed :
  Do you wish to apply for discount and agree to set the alarm whenever your home is unattended?

  Have you fitted the required door and window locks/bolts?
  Do you wish to apply for the discount and agree to use all the required locks/bolts whenever your home is unattended?
  Do you require building Cover?
  (Only complete if you require Buildings Insurance)
  Value of Building?
  Do you require Standard Cover? :
  Do you require Accidental Damage cover? :
  Do you wish to delete the £50 excess? :
  Do you wish to increase this £50 excess? :
  Give name and address of any interested party (e.g. mortgagee, freeholder, or leasee) who you wish to be noted on this policy :
  Do you require Contents Cover?
   Contents. (Only complete if you require Contents Insurance)
  Value of Contents?
  Do you require Standard Cover? :
  Do you require Accidental Damage Cover? :
  How many bedrooms are there in the house? :
(A bedroom is a room used or originally built to be a bedroom even if now it is used for other purposes
  Is £30,000 adequate to cover the full replacement cost of your contents? :
  I have not made a claim for loss of or damage to Contents or Personal Possessions in the last 3 years and I wish to apply for the introductory discount :
  Personal Possessions (Only available if contents are insured)
  UNSPECIFIED TERMS: State the amount to be insured for clothing, baggage, other items of personal use normally worn or carried (including silver and gold items) jewellery, watches, binoculars, telescopes, furs and sports equipment etc. :
  SPECIFIED ITEMS (Minimum amount insured £2000. Any one item may not exceed 25% of the amount or £1000, which ever is the lowest)
  Do you require Legal Protection? :
  Are you in a neighbourhood watch area? :
  IMPORTANT: Please state any other relevant information in this space.