Please fill in the form below

Personal Details  
Email:
Date:
(mm/dd/yy)
Tel No.:
Fax No.:
Name:*
Date of birth: (mm/dd/yy)
Occupation:
Nature of employer's business:
Current insurer:
Renewal premium:
Renewal date: (mm/dd/yy)
Current excess
Have you ever had insurance cancelled, refused, or any terms imposed? Yes No

Risk Detail  
Address of property to be insured:
 
 
  Postcode:
Policy excess required £100   £250  £500


  Yes No
year of construction:  Listed:
If yes give details below    
Standard Construction?
(Brick, stone, slate and tile)
Regularly occupied?
Signs or history of subsidence, heave or landslip
Business use?
History of flooding or or within 400m of a watercourse?
Undergoing/Due to undergo renovations of works?
     

Security  
  Yes No
5 lever Mortice Deadlock on external doors?
If no, please provide details below    
Key operated window locks?
Alarm with NSI/SSAIB maintenance contract?
Bell/siren only Digital Communicator
Dualcom Redcare
GSM Redcar Other
   
Safe?
     
Manufacturer:
Model:
Cash rating:

Buildings Cover  
Main Building sum insured:
Outbuildings Sum insured:

Contents Cover  
General Contents:
(Excluding the following)
Personal possessions:
(Excl. jewellery)
Unspecified jewellery:
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)


Guns:
Collections:
Others:

Claims history in last 5 years?  

Any additional information