Building & Contents Insurance Quotation

Building & Contents Quotation

Personal Details

Proposer :

First Name : Surname :

D.O.B. : dd/mm/yy Occupation :

Spouse/Joint Proposer :

First Name : Surname :

D.O.B. : dd/mm/yy Occupation :

Address :


Postcode :


Telephone inc. STD code	Home :	Fax :
Telephone inc. STD code	Mobile :	Work :

Email :

Have you lived at this address for the last 3 years ? : Yes No

If less than 3 years please give previous address

Address :


Postcode :

General Questions

Do you require : Building Insurance Contents Insurance Both

Is the Home for which insurance is required

a)	Built of brick, stone or concrete walls ? :	Yes No
b)	Roofed with slate, tile, asphalt, metal or concrete ? :	Yes No
c)	Self-contained, having its own separate, lockable front door ? :	Yes No
d)	Protected by window and door locks ? :	Yes No
e)	Occupied solely by you and your family as a permanent residence ? :	Yes No
f)	Used as a private residence only and not as business premises ? :	Yes No
g)	In a good state of repair, and will this be maintained ? :	Yes No

If the answer to any of the above is NO then please give details below

Is the home a

a)	House	Bungalow	Flat	Other
If a house or bungalow is it
b)	Detached	Semi-Detached	Terraced	Other
c)	Owner occupied	Rented Furnished	Rented Unfurnished	Other

If the answer to any of the above is OTHER then please give details below

When was the home built (approx) : dd/mm/yy

Number of bedrooms in house :

Has this house ever been damaged by flood, subsidence, heave or landslip in the area ? :		Yes No
To the best of your knowledge is there any history of flood, subsidence, heave or landslip in the area ? :		Yes No
Is the home for which insurance is required
a)	Occupied as a holiday home ? :	Yes No
b)	Regularly unoccupied throughout the day or night ? :	Yes No
c)	Ever left unoccupied for a period in excess of 30 days ? :	Yes No
Have you, or any member of your family, or any person living with you
a)	Ever had any insurance cancelled, refused or subjected to special terms ? :	Yes No
b)	Suffered any loss or damage (whether it resulted in a claim or not) in the last five years ? :	Yes No
c)	Made a claim in the last five years or had a claim made against you ? :	Yes No
d)	Ever been convicted or charged (but not yet tried) or given a Police Caution in respect of any criminal offence ? :	Yes No
e)	Been declared bankrupt, or had a controlling interest in a company or partnership which has become insolvent or gone into liquidation, or been subject to (or have pending) a CCJ or SCD in the last three years ? :	Yes No

If the answer to any of the above is YES then please give details below

Have you or any member of your household ever held Yes No

or currently hold any form of home insurance ? :

Please give details or reasons why no insurance is held below

Buildings Insurance

Please enter the amount to be insured (minimum £35,000) : £

Do you wish to accept a voluntary excess for a discounted premium ? : Yes No

(We will contact you with details)

If Yes, please select or enter the amount : £50 £100 £250 Other £

Are you the sole owner(s) of the building to be insured ? : Yes No

Please state name and address of other interested parties

(e.g. Mortgagee / Other owner)

Name :
Nature of Interest :

Address :


Postcode :

Contents Insurance

Do you require accidental damage cover for your contents whilst in your house, domestic out building or garage ? :	Yes No
Please enter the amount to be insured (including High Risk Items) : (do not include any items you are insuring separately)	£
Does the total replacement cost of all High Risk Items exceed one third of your Contents amount insured ? :	Yes No
If Yes, please advise amount insured required for High Risk Items	£
Do you wish to apply for the Intruder Alarm discount ? :	Yes No
If Yes, please give the name of the installing company below

Do you wish to accept a voluntary excess for a discounted premium ? : (We will contact you with details)	Yes No
If Yes, please tick or enter the amount : £50 £100 £250 Other £

Personal Possessions

This section covers articles that you take out of your home in everyday life.

There are two parts to this section and you may select one or both.

Unspecified Items

The amount insured should represent the maximum value of all property you are likely

to have away from home at any one time. Items worth more than £1,000 and pedal cycles

worth more than £200 should be listed under Specified Items.

Amount insured required (minimum £2,000 / maximum £75,000) £

Specified Items

Please provide details of pedal cycles over £200 and personal possessions over £1,000.

Those items should not be included in the Contents amount above.

Description	Replacement Value
1	£
2	£
3	£
4	£
5	£

Disclaimer

To the best of your knowledge and belief

All the above statements are true and complete and no material facts have been withheld, suppressed or omitted. A material fact is any fact which could influence the assessment or acceptance of this Proposal. Failure to tell us a material fact may lead to any claim being invalid. If you are in any doubt as to whether facts are material or not, then you should disclose them.

How can we contact you :

Tel. (home) Tel. (work) Tel. (mobile) Post Fax Email

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