Home Insurance Quote Form

For UK Customers Only

Please insert your details here and we will provide you with a competitive home insurance quote shortly from our wide range of insurers.

This quotation form is designed for proposers wishing to insure their buildings and/or contents for their main residence only and not for properties let to tenants. Please also refer to us if any business activities are carried out from the home.

If you have any problems completing this form, please phone us on 01623 641 386 for assistance.

Proposers Details

1st Proposers Details
Status:
First Name:
Surname:
Marital Status:
Address of property to be insured:
Postcode:
Correspondence address: (if different from above)
Date of Birth:	(dd/mm/yyyy)
Occupation:
Employers Business:
Employment Status:
Contact Details
Daytime Telephone No.:
E-Mail Address:

Do you wish to add a second proposer?	Yes No
2nd Proposers Details
Status:
First Name:
Surname:
Relationship to Proposer:
Date of Birth:	(dd/mm/yyyy)
Occupation:
Employers Business:
Employment Status:

General Information

Approximate year the property was built:
Type of property:
Property Construction
Construction of Walls
Construction of Roof
Percentage flat roofing (if applicable):	%
No. of bedrooms:
Number of storeys:
Have you, or any other family member ever been convicted of any offences, been declared bankrupt or had any insurance refused or cancelled?	Yes No
If yes, please provide details: (e.g. type of incident, date(s), amounts of bankruptcy, fines, custodial sentence, etc.)
Has there ever been any subsidence or flood damage at the property?	Yes No
If yes, please provide details:	Date of claim 1: Cost of claim:£ Type of claim: ----- Date of claim 2: Cost of claim:£ Type of claim: ----- Date of claim 3: Cost of claim:£ Type of claim: ----- Unfortunately, we are unable to provide a quotation if you have exceeded 3 claims. -----
Is the property in a good state of repair?	Yes No
If no, please provide details:
Has the property ever been underpinned?	Yes No
If yes, please provide details:
Is the property grade listed? (e.g. grade I, II, etc.)
Property ownership:
Occupancy
Occupancy:
Are you, or any other persons who reside at the property smokers?	Yes No
Is the property currently unoccupied?	Yes No
If yes, please provide details of how long it has been unoccupied:
Is the property ever unoccupied for more than 30 days?	Yes No
If yes, please provide details:
Security
Level of security: (Tick whichever are applicable)	NACOSS/NSI approved alarm fitted Smoke Detectors Member of Neighbourhood Watch 5 Lever Mortice Locks for Exterior Doors and Key Operated Window Locks
Insurance History
Do you currently hold home insurance?
If yes, please indicate how many years you have held home insurance:
Claims History/Experience
Have you had any claims in the last 5 years?	Yes No
If yes, please provide details:	Date of claim 1: Cost of claim:£ Type of claim: ----- Date of claim 2: Cost of claim:£ Type of claim: ----- Date of claim 3: Cost of claim:£ Type of claim: ----- Unfortunately, we are unable to provide a quotation if you have exceeded 3 claims. -----

Buildings Insurance Details (for home owners only)

Buildings Sum Insured (£'s)	(Standard Perils Cover) Help?
Accidental Damage Cover:	(Click box if accidental damage cover is required)
Contents Insurance Details

Contents Sum Insured (£'s)	(New for Old Cover) Help?
Accidental Damage Cover:	(Click box if accidental damage cover is required)
Extra Cover (optional)

Is cover required for your personal possessions away from your home? (e.g. clothing, jewellery, etc.)	Yes No Help?
Please state the sum insured for personal possessions away from the home: (Standard cover is for £2,000)
Would you also like to include cover for pedal cycles away from the home?	Yes No
Number of pedal cycles:
Highest value pedal cycle to be insured:

Specified Item(s)

Individual valuables or jewellery are usually restricted to £1,500 per item unless specified.
Do you wish to specify any valuables or jewellery?	Yes No
Please provide details of any special items / valuables over £1,500 that you wish to specify on your policy:

Item	Description (e.g. 18ct gold ring)	Value (£'s)
1.
2.
3.
4.
5.

Renewal/Cover Start Date

Home Insurance Renewal / Cover Start Date:	(dd/mm/yyyy)

Request Quotation

Disclosure
Please ensure that all the information you have provided is correct and that you have answered all the questions accurately then press the Request Home Insurance Quotation button and we will contact you shortly with a quotation.