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Ever had a proposal for insurance, declined, renewal refused, cover terminated, increased premium or special conditions imposed by any insurer?* YesNo
Sustained any loss, damage, injury or liability in the last 5 years, whether insured or not, from any of the events you wish to insure against?* YesNo
Ever been convicted or, or cautioned for (or charged with but not yet tried for) any criminal offence (other than motoring offences)* YesNo
Ever been declared bankrupt, been subject to any individual voluntary arrangement (IVA) or County Court Judgement (CCJ) or had any debt relief order?* YesNo
Title* MrMrsMissMsOther
First name*
Surname*
DOB*
Occupation*
Email Address*
Contact Telephone Number*
Title MrMrsMissMsOther
First name
Surname
DOB
Occupation
Renewal Date
Current Insurer*
Current Premium*
Address Line 1*
Address Line 2
Town*
Postcode*
Property Type —Please choose an option—Detached houseDetached bungalowSemi-detached houseSemi-detached bungalowTerraced houseTerraced bungalow
Number of Bedrooms —Please choose an option—12345+
Year of build*
Contruction* StandardNon-Standard
Buildings
Cover —Please choose an option—Accidental DamageStandard
Outbuildings
Unspecified Personal Possessions (Total value of items, including Jewellery & Watches taken away from the home with individual values of less than £2,000)
Specified Personal Possessions (Individual value of items, including Jewellery & Watches taken away from the home with individual values of £2,000 or more)
Garden Cover
Money Cover
Fine Art
Guns
Any Other Collections
Legal Expenses
Are all accessible windows fitted with key operated locks?* YesNo
Are all final exit doors fitted with PVC/5 lever mortice deadlocks?* YesNo
Is there an Alarm at the property?* YesNo
Make of alarm
Signalling Method —Please choose an option—BellsCentral StationMobile Phone
Is there a safe at your property?* YesNo
Make and model of safe
Cash rating
Any other security? CCTV/Security gates/Guard dogs etc YesNo
If yes, please state
Claim 1 Date
Claim 1 Incident
Claim 1 Amount Paid
Claim 1 Settled? YesNo
Claim 2 Date
Claim 2 Incident
Claim 2 Amount Paid
Claim 2 Settled? YesNo
Accidental Damage Extension on Buildings YesNo
Accidental Damage Extension on Contents YesNo
Money Cover YesNo
Family Legal Expenses YesNo
Garden Cover YesNo
Signed*
Date*
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