Proposer Required if Joint Names  
Title  
Forenames  
Surname  
Date of Birth 

 
   
Occupation  
   
Telephone  
Previous Insurer Renewal Date  
Address to be insured.    
  Postcode
  Email
 
Year Property Built    
Covers Required  
Buildings Sum Insured Rebuilding Cost Accidental Damage Cover  
What is the total value of your contents?    Accidental Damage Cover  
Highest Value any one item >£1500 Total value of items over £1500
All Risks Cover   Freezer Contents
    Bicycles
Do you require cover for property outside the home?    
Have you had any losses in the last 5 years?             
Mortgage Provider if applicable  
Are the premises usually occupied during the day? Are the premises usually occupied during the night?
Do you have good quality security locks on all external doors and windows? Do you have an intruder alarm installed?    
Do you have smoke detectors? Are you a member of a Neighbourhood Watch Scheme?
Has the property ever experienced
Is the property within 400 metres of a river or cliff?
Do you have any other comments that may be relevant?