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1st Proposer's Details |
Status: | |
First Name: | |
Surname: | |
Marital Status: | |
Address of property to be insured: | |
Postcode: | |
Is the correspondence address the same as the address shown above? | Yes No |
Correspondence address: (if different from above) | |
Date of Birth: | (dd/mm/yyyy) |
Occupation: | |
Employer's Business: | |
Employment Status: | |
Do you live permanently at the address to be insured? | Yes No |
If no, please provide details: | |
2nd Proposer's Details (if applicable) |
Do you wish to add a second proposer? | Yes No |
Status: | |
First Name: | |
Surname: | |
Relationship to Proposer: | |
Date of Birth: | (dd/mm/yyyy) |
Occupation: | |
Employer's Business: | |
Employment Status: | |
Contact Details |
Daytime Telephone No.: | |
*E-Mail Address: | |
*Please note that your email address will only be used to provide you with your quote and not for any other marketing purposes. |
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Preliminary Information |
Have you, or any other proposer had any previous insurance declined, renewal refused or any special terms imposed? | Yes No |
If yes, please provide details: (e.g. date policy was declined/refused/special terms imposed, reason for declinture/refusal/special terms, etc.) | |
Have you, or any other family member ever been convicted of any criminal offences, other than those spent under the rehabilitation of offenders act? | Yes No |
If yes, please provide details: (e.g. reason for conviction, date(s) of conviction, length of any custodial sentence, details of any fines (if applicable)) | |
Have you, or any other family member ever been made bankrupt, or had a County Court Judgements (CCJ's), or entered into any Individual Voluntary Arrangements (IVA's)? | Yes No |
If yes, please provide details: (e.g. date(s) of bankruptcy/CCJ/IVA, amounts of bankruptcy/CCJ/IVA, has the bankruptcy been discharged?, and/or have any CCJ's/IVA's been settled?) | |
Year Built / Property Type |
Approximate year the property was built: | (yyyy) |
Type of property: | |
Property Construction |
Construction of Walls | |
Construction of Roof | |
Percentage flat roofing (if applicable): | % |
No. of bedrooms: | |
No. of bathrooms (incl. en-suites): | |
Number of storeys: | |
Has there been, or is the property showing any signs of any subsidence or ground movement? | Yes No |
If yes, please provide details: (e.g. date of damage, details of damage cost of damage £'s) | |
Has the property ever been, or is it currently being monitored for subsidence, heave or landslip? | Yes No |
If yes, please provide details: | |
Has the property or any properties nearby ever previously been affected by flood damage? | Yes No |
If yes, please provide details: | |
Is the property in a good state of repair? | Yes No |
If no, please provide details: | |
Is the property near a river or quarry? (i.e. within 250 metres) | Yes No |
If yes, please state whether near a river or a quarry and the approximate distance: | |
Is the property grade listed? (e.g. grade I, II, etc.) | |
Has the property ever been underpinned? | Yes No |
If yes, please provide details: | |
Do you have any trees over 3 metres (10ft) within 7 metres (20ft) of the property? | Yes No |
If yes, please confirm the type of trees: (e.g. birch, willow, oak, sycamore, etc.) | |
How close are the trees to the property? | |
Use / Occupancy |
Property ownership: | |
Occupancy: | |
Is the property currently occupied? | Yes No |
If no, please provide details of how long it has been unoccupied and how long before the property will be occupied: | |
Is the property ever left unoccupied for more than 30 days? | Yes No |
If yes, please provide details: | |
Is any business use carried out from the premises? | Yes No |
If yes, details of business activities: | |
Is the property used as a holiday home or a second home? | Yes No |
Is the home occupied by paying guests / lodgers? | Yes No |
If yes, number of paying guests / lodgers: | |
Do you, or any other persons who reside at the property smoke? | Yes No |
Security |
Is the property self-contained with its own lockable entrance? | Yes No |
Level of security: (Please tick all that are applicable) | NACOSS/NSI approved alarm fitted Smoke Detectors Member of Neighbourhood Watch 5 Lever Mortice Locks (B.S. 3621) for Exterior Doors and Key Operated Window Locks |
Please confirm type of locks on patio doors, french doors, bi-fold doors or sliding doors: (If no patio doors, please select 'No Patio Doors' from the dropdown list) | |
Surveys / Extensions |
Have any surveys or engineers reports been carried out on the property? | Yes No |
If yes, please provide details: | |
Has the property ever been extended? | Yes No |
If yes, year extended: | |
NB. Extensions and/or annexes will be included under the cover provided they are within the property boundary. |
Heating |
Please confirm your primary heating type: | |
Insurance History |
Do you currently hold home insurance? | Yes No |
If yes, please indicate how many years you have held home insurance: | |
Claims History/Experience |
Have you or any other person living in the property had any household claims, loss, damage or any other incidents suffered in the last 5 years whether the loss, damage or incident was insured or not? | Yes No |
If yes, please provide details: |
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Buildings Sum Insured (£'s): (Please enter the amount required to rebuild the property allowing for demolition costs, site clearance and professional fees.) | |
Buildings Level of Cover? (Standard cover includes fire, theft, lightning, explosion, earthquake, storm, flood, escape of water, subsidence, etc. Accidental damage cover is provided in addition to the above.) | Standard Cover & Accidental Damage Cover Standard Cover only
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Contents Sum Insured (£'s): (Cover is on a 'New for Old' basis and the contents sum insured should represent the replacement value of the entire contents as new, e.g. £75,000) | |
Contents Level of Cover? (Standard 'New for Old' cover includes fire, theft, lightning, explosion, earthquake, storm, flood, escape of water, etc. Accidental damage cover is provided in addition to the above.) | 'New for Old' & Accidental Damage Cover Standard 'New for Old' Cover
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Unspecified Personal Possessions |
Is cover required for your Personal Possessions away from your home? (e.g. clothing, jewellery, etc.) | Yes No
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Please state the sum insured required for unspecified personal possessions away from the home: (Minimum level of cover is £2,000) | |
Pedal Cycles |
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: | |
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Specified Item(s) |
Individual valuables or jewellery are usually restricted to £2,000 per item unless specified. |
Do you wish to specify any valuables or jewellery? | Yes No |
Please provide details of any special items / valuables over £2,000 that you wish to specify on your policy: |