Date of birth:
Nature of employer's business:
Have you ever had insurance cancelled, refused, or any terms imposed?
Address of property to be insured:
Policy excess required
year of construction:
If yes give details below
(Brick, stone, slate and tile)
Signs or history of subsidence, heave or landslip
History of flooding or or within 400m of a watercourse?
Undergoing/Due to undergo renovations of works?
5 lever Mortice Deadlock on external doors?
, please provide details below
Key operated window locks?
Alarm with NSI/SSAIB maintenance contract?
Main Building sum insured:
Outbuildings Sum insured:
(Excluding the following)
Specified jewellery (single article limit £5000 or more)
Gold silver plate:
Jewellery in the bank:
Paintings, fine arts and antiques:
(Do not include any item over £1500 - specify bellow)
Claims history in last 5 years?
Any additional information