
	Serving the public since 1975

Home insurance

About you

Title
Sex
Forename(s)
Surname
Date of birth	(dd/mm/yyyy)
Occupation (full and part time)
Contact number
Home
Work
Mobile
Email
Risk address postcode

Title
Sex
Forename(s)
Surname
Date of birth	(dd/mm/yyyy)
Occupation (full and part time)

1. Have you or anyone who normally lives with you:
a) suffered loss or damage or liability anywhere during the last three years, whether insured or not, and which would be insured under the covers you are choosing?
b) had any insurance cancelled or turned down or had any special terms applolied to your insurance?
c) ever been convicted of or charged (but not tried yer) with any offence other than a driving offence?
d) had any insurance of this type before? If yes give details.
2. Is your home in a good state of repair	Yes No
3. Is your home
a) built of:
b) roofed with:
4. Is your home:
a) live in only by you or your family?	Yes No
b) live in or used in any way for trade professional or business purposes?	Yes No
c) usually left without an adult in any time day or night?	Yes No
d). likely to be left unoccupied for more than 30 days at a time?	Yes No
5.
a) Is your home:
b) If your home is a house or bungalow; is it?
c) If you have a flat, is it?
d) If you have a flat, what floor is it on?
e) Are you a member of a Neighbourhood Watch scheme?	Yes No
f) How many bedrooms does your home have?
g) How long have you lived in your home?
6) In what year was your home built?
7) Are you:

Fill in only if you want contents cover included in your quote
Sum assured
Do you want to include accidental damage?	Yes No

Sum insured
Personal Money
Pedal cycles	Make £ Make £ Make £
Single articles valued at, near to or above £1,500.	Description £ Description £ Description £

Fill in only if you want buildings cover included in your quote
What is the total cost of rebuilding your home?	£
Do you know about any past or existing structural damage to your house?	Yes No If yes give details
Has your home been underpinned or provided with other structural support?	Yes No If yes give details
Does anyone else have financial interest in your home? If yes please give details	Yes No If yes give details

When is your current policy due for renewal.

/ /

Please fill in all of this part:
Are all easy to reach windows, fan lights, or other openings which permit entry fitted with key-operated locks?	Yes No
Is your home fitted with an alarm which is maintained by a NACOSS or SSAIB approved installer?	Yes No
Do all your exit doors have 5 lever mortice deadlocks fitted to them.	Yes No