-- 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
How many years no claims on previous buildings insurance?
Is contents cover required?
-- Please select --
Yes
No
Total Sum Insured
How many years no claims bonus on previous contents cover?
For how long has the property been unoccupied?
90 days or less
91 days to 1 year
more than a year
What is the long term intention?
To be owner occupied
To be let after 90 days
To be sold
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.
