Private Home Insurance Quote Form

Please Read This Statement Before Completing The Form

The quotations we provide you will be based on the following:

The property & surrounding area is Free from storm/flood/subsidence/ground heave & landslip & has no history of such events in the area.
The property is in a good state of repair & will be so maintained.
The property or neighbouring properties have never been repaired, monitored in connection with, or suffered damage by subsidence, landslip or ground heave or been underpinned.
You have not had a previous insurance policy declined or refused, or had any criminal convictions or been made bankrupt.
There is no business run from the property.
The property is your main permanent residence and not a second home or left unoccupied.

N.B. If you cant agree with the above statement or are not sure about the statement then please ring us on 01288 353999 where we will be more than pleased to offer a quotation over the phone.

Proposer's Details

Proposer's name:

Date of birth:

Occupation:

Employers business:

Is there a joint proposer (e.g. spouse):

YesNo

(If applicable:)

Joint Proposer's full name:

Joint Proposer's Date of birth:

Joint Proposer's Occupation:

Joint Proposer's Employers business:

Relationship to the main proposer:

Property Details

Risk Address:

Risk Address Postcode:

Property type:

Year property originally built:

Is the property a listed building?

Has the property ever been extended:

YesNo

If Yes, What was the extension and what year was the extension built?

Number of bedrooms:

Construction (Walls):

Construction (Roof):

What percentage of flat roof is on the property:

When did you purchase or move in to this property:

Are all final exit doors fitted with at least a '5 lever mortice deadlock' approved to (BS3621):

YesNo

Do you have key operated locks on all accessible windows:

YesNo

Are you a member of a neighbourhood watch scheme:

YesNo

Do you have working smoke alarms fitted in the house:

YesNo

Number of adults who live at the address:

Number of children who live at the address:

Does any member of the household smoke:

YesNo

Is the property within 400 metres of a river, watercourse, river, canal, sea, cliff or quarry or in a flood or subsidence risk area: (if 'Yes' please put what and how far away in box below):

YesNo

Do you own or rent the property:

Have you made any household claims in the last 5 years: (If 'Yes', please put dates, descriptions and costs of claims in box below)

YesNo

Any further information or material facts, please enter here:

Cover Details

Buildings: This is the rebuilding cost of your property. Includes the main property, small private outbuildings like garages, plus architects fees and debris removal. It is not based on the current value of the property.

Contents: This covers all personal contents (i.e. furniture, carpets, TV's etc).

Personal Possessions: This covers contents whilst taken away from the property. This is split in to 'unspecified' possessions for cheaper items and for more expensive items taken away it may be advisable to individually 'specify' them.

Do you require Buildings Cover? :

YesNo

If Yes: What is the Buildings Sum Insured: £

and would you like a quote including 'accidental damage' cover:

YesNo

Do you require Contents Cover? :

YesNo

If Yes: What is the Contents Sum Insured: £

and would you like a quote including 'accidental damage' cover:

YesNo

Do you require Personal Possessions Cover? :

YesNo

If Yes: 'Unspecified' Personal Possessions Sum Insured: £

'Specified' Personal Possessions. Please enter full description of each specified item and it's replacement value:

How many years have you been claim free on current policy:

Other Information

Your Current insurers:

Renewal/Inception date:

Renewal/Target premium: £

Do you have any further information you feel may affect the quotation:

Other Information

Contact Name:

Correspondence address:

Email address:

Phone number:

How to contact you:

Private Home Insurance Quotation Form

Please Read This Statement Before Completing The Form

Proposer's Details

Property Details

Cover Details

Other Information

Other Information

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