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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
Type of Tenant —Please choose an option—DHSSProfessionalLet Student
Buildings
Contents
Money Cover
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
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
Rent Guarantee Cover YesNo
Legal Expenses YesNo
Signed*
Date*
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