-- Please select --
Search Engine
Existing Client
Friend / Family
Online Directory
Other
UNLOCK
If other please specify:
Sex
-- Please select --
Male
Female
Title
First Name
Surname
Date of Birth
Marital Status
-- Please select --
Single
Married
Divorced
Separated
Married Common-law
Widowed
Occupation
Type of business
Email Address
Telephone Number
Is policy to be in joint names?
-- Please select --
Yes
No
Sex
-- Please select --
Male
Female
Title
First Name
Surname
Date of Birth
Marital Status
-- Please select --
Single
Married
Divorced
Separated
Married Common-law
Widowed
Occupation
Type of business
(please list 1,2,3 in each section if you have more than 1 conviction)
Name of Convicted Person
(If convicted person is not one of the policyholders detailed above - please also list their Date of Birth & Occupation.)
Date of Offence
Date of Conviction
Type of Conviction
(e.g GBH, Common Assault)
Sentence given by court
(e.g. 5 years custodial or 100 hrs community service)
Sentence actually served
(e.g. served 2 years then 3 months on tag)
Description of Incident
(Please give as much information as possible)
Mitigating Circumstance
(e.g. had drink problem at time now recovering alcoholic etc.)
House Name / Number
Full Address
Postcode
House Name / Number
Full Address
Postcode
Property type
No. of Bedrooms
Wall Construction
Roof Construction
No. of Storeys
Year built
Listed Building
-- Please select --
Yes
No
Is the property in an area with a history of floods?
-- Please select --
Yes
No
Are there key operated window locks?
-- Please select --
Yes
No
Is Buildings Insurance required?
-- Please select --
Yes
No
Cost to rebuild property / Sum insured
Is Accidental Damage cover required
-- Please select --
Yes
No
How many years no claims on previous buildings insurance?
Is contents cover required?
-- Please select --
Yes
No
Total Sum Insured
Is Accidental Damage required?
-- Please select --
Yes
No
How many years no claims bonus on previous contents cover?
Duration of Leasing Agreement?
Short Term- 6 Months or more
Short Term- less than 6 months
Long Term- e.g. 99 yr Leasehold
Leasing agreement will be between the freeholder and the -
Tenant
Managing Agent
DSS/Local Authority
Housing Association
Does the tenancy agreement allow tenant to sublet?
No
Yes
Number of Tenants?
Note1: If the property being occupied is a flat(s), please indicate the maximum number of tenants in any one flat.
1 Tenant/Family
2 Tenants
3 Tenants
4 Tenants
5 Tenants
6 Tenants
7 Tenants
8 Tenants
9 Tenants
10 Tenants
Type of Tenants?
Note: If the premises are multi-tenured, indicate the catagory of tenant with the highest risk
Asylum Seeker
Student(s)
Tenant (DSS Benefit)
Professional (Working)
Retired
Will cooking be allowed in any area other than a clearly designated cooking area
No
Yes
You or any other joint owners have never:
Suffered any loss or incurred any liability, whether insured or not, during the last 3 years as a result of the risks proposed (whether at this or any other premises) or had any claims made against you?
Been convicted of, or in the course of being charged with, any offence (excluding driving offences) whether at these premises or elsewhere?
Been declared bankrupt or been a director of any company that went into liquidation?
Had any insurance declined, cancelled, refused or had any special terms applied by any Insurer for the risks proposed?
The premises are:
- In a good state of repair and will be so maintained
- No part of the property is used for commercial business
Do you agree with the above statements?
If no, please state reasons why:
Please give FULL details of any claims made on either Buildings or Contents insurance within the last 5 Years
Date Cover to commence
Current renewal premium, if applicable
Current Insurer, if applicable
Please add any information you feel may affect the quotation.
