Title	-Please Choose- Mr Mrs Miss	Forenames		Surname
Company Name		Business Type	-Please Choose- Partnership Limited Company Sole Trader
No and street		Town		Postcode
Email		Telephone

Occupation

<-Please Select-> Accountant actuarial consultancy Actuary Acupuncturist Addressing/circularising services Adjuster Advertising consultant Aerial erector Agricultural consultancy Agricultural producer Animal breeding Animal feeds Animal rescue home Antique dealer Aquarium suppliers Arbitrator Architect Architectural surveying Archivist Artist Assessor Astrologer Astronomer Auctioneer Auditor Author Babywear retailer Bagpipe maker Bakery Barrel makers Barrister Basket and/or brushware Bathroom design Bathroom installation Beautician Belts/scarves/gloves retailer Blacksmith Book-keeper Bookmaker - off course Bookmaker - on course Booksellers Bridal wear retailer Builder Business advisory service Business consultancy Cabinet maker Carpenters and joiners Carpet fitting Cartographer Cartoonist Catalogue co-ordination Catalogue distribution Caterer Catering consultant Cattery Chartered surveyor Child minder Chimney sweep China and/or glassware retailer Chiropodist Chiropractor Cleaning contractor Clerical services Clock & watch repair Clothing hire Clothing hire - fancy dress Clothing retailer Clothing trade Coin & medal dealer Commodity dealer Community action group Computer consultant Computer programmer Computer software Confectionery manufacturer Conference management Consultant engineer Conveyancer Copywriter Correspondence school Corrosion consultancy Curtain and blind fitters Curtain maker Cycle repairer Data processor Dental technicians (laboratory/workshop) Dentist Design consultancy Desktop publishing services Dietician Doctor Doll maker Domestic appliance maintenance Double glazing installers Drain cleaners Drapery Draughtsman Dressmaker Driving instructor Editorial consultancy Electrician Embroiderer Employment agency Employment agency - clerical Energy consultancy Engineering consultants Environmental consultant Estate agent Exhibition designer Export consultancy Fence erector Financial advisor Fire protection consultancy Fitness instructor Flooring contractors Florists Flower arranger Freight forwarders French polisher Furniture manufacture Garden equipment retailer Gardener Genealogist Glass worker Glazier Graphic designer Graphologist Greeting card sales Haberdasher Hairdresser Handicraft retailers Health and safety consultant Health products distribution Heating and ventilation contractors Heating consultant Herbalist Honey producer Horticultural consultancy Horticultural goods retailer Hotel consultant Human rights organisation Ice cream vendor Import consultancy Import/export Industrial consultant Insurance advisor Insurance assessor Insurance broker Insurance consultant Insurance intermediary Interior design Interpreter Investment consultancy Investment management Ironing services It consultancy Journalist Kennels Kitchen installation contractors Kitchen planners Knitter Lampshade maker Landscape architect Legal advisor Licensing consultant Linen retailer Lingerie retailer Linguistics Loft insulation Loss adjustor Loss assessing Mail order Management consultant Management training Manicurist Marine broker Marine consultancy Market research Marketing consultant Medical consultancy Metal worker Milk delivery Mining consultancy Mobile hairdresser Model maker Money broker Mortgage broker Music teacher Naval architects None Notaries Nursery school Occupational health consultant Office services Opinion polls Osteopath Paint consultancy Painter and decorator Party planner Patent agent Personnel consultancy Pet minder Pet parlour Photographer Photographic equipment retailers Physiotherapist Piano tuner Picture framer Planning consultancy Plasterer Plastics consultancy Plumber Political consultancy Potter Press cutting agency Press office Printer Professional association Project management Promotional consultancy Property consultants Property services Public relation consultancy Publicity management Publisher Quantity surveyor Record cd cassette & vidoe retailer Recording services Relocation agency Research consultant Researcher Roofer Rug maker Saddler Safety consultancy Sales representative Sample distribution Scientific research Script writing Sculptor Seamstress Secretquote services Secretary Security consultant Sharpening services Shipping and forwarding agency Shop fitter Sign maker Signwriter Slater Slimming aids distribution Soft furnishings retailer Software consultancy Solicitor Sports goods shop Stamp dealers Stationer Stockbroker Stonemason Surface coating consultants Surveyor Tailor Tax consultant Taxi operator Teacher Telecommunications Telecommunications consultancy Telemarketing Telephone answering service Telesales Telex bureau Textile consultancy Tiler Toiletries retailer Town planning Toy maker Trade association Trade union Training advisory service Training board Training consultancy Training consultant Translator Travel consultant T-shirt printer Turf accountant Typesetter Typist Underwriter Upholsterer Valuer Veterinary surgeons Voluntary organisation Weather services Window cleaner Wood carver Word processing Word processing operator Yarn spinning Zoology consultancy

f not listed specify here

Have you;
-had any losses in the last 5 years?	Yes No	if yes please give details
-had and special terms imposed or insurance cancelled?	Yes No	if yes please give details
-ever been convicted or charged and not yet tried for any offence other than motoring?	Yes No	if yes please give details
-been declare bankrupt or been the subject of bankruptcy proceedings?	Yes No	if yes please give details
Name of existing household Insurer

Buildings	Do you require this cover?	Yes No	What is the rebuilding sum insured?	£
Contents	What is the total value of your home contents?			£
	Is the total amount of valuables in excess of 25% of the total figure	-Please Choose- Yes No	If yes what is the total sum insured for valuables	£
	What is the value of your business contents?	£	What is the value of any computer equipment	£

Is your home

Ownership Owned Rented privately Rented (Public Sector) Property Type Detached House semi detached house terraced/town house detached bungalow semi detached bungalow self contained flat maisonette Number of Bedrooms 1 2 3 4 5 more Wall Construction Brick Concrete Stone Wood Other Roof Construction Slate Tile Timber Felt Thatch Security No Alarm Bells only Dialler BT Redcare

Numbers of Staff / Employees	-Principals or Directors- One Two Three Four Five -Manual Employees- One Two Three Four Five -Clerical Employees- One Two Three Four Five
Do you have any other comments that may be relevant? if so please give details