Name		Date of Birth	Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Address of Property
		Postcode

Telephone Number		Email Address		Occupation
Year Built   Listed Property Grade I Grade II Two Star No Good State of Repair Yes No Last Electrical Inspection 1 Year 2 Years 3 Years 4 Years 5 Years Over 5 Years Percentage Thatch Roof 100% 90% 75% 50% 25% 10%
Wall Construction       Nature of Property Permanent Home Holiday Home - Not let Holiday Home - Let Weekend Home Other Number of Open Fires 0 1 2 3 4 5 Woodburning stoves Yes No Multifuel Stove Yes No
Type of Thatch Water Reed Long Straw Combed Wheat Devon Wheat Reed Norfolk Reed Date rethatched      Last inspected by thatcher Chimneys Swept Annually Yes No Are the Chimneys Lined Yes No
Is the chimney at least 1m above thatched roof?	Please Choose Yes No	Is a Spark Arrestor fitted to chimney?	Please Choose Yes No	Are at least 2 fire extinguishers in place one in kitchen?	Please Choose Yes No
Room Treated with fire retardant?	Please Choose Yes No
Building Sums Insured		Contents Sums Insured		Jewellery/Personal Effects sum insured
Personal Money		Pedal Cycles

Is the property fitted with mortice dead locks on the final exit doors?	Please Choose Yes No	Neighbourhood Watch member?	Please Choose Yes No
Have you had any losses or made any claims in the last three years?	Please Choose Yes No	if yes please provide details
Has the property/area a history of storm, flood, subsidence, landslip or heave?	Please Choose Yes No	if yes please provide details
Ever been refused cover or has additional terms applied by your insurer?	Please Choose Yes No	if yes please provide details
Key operated window locks on all accessible windows?	Please Choose Yes No	Do you have a NACOSS/SSAIB Approved Alarm?	Please Choose Yes No
Previous Convictions?	Please Choose Yes No	if yes please provide details
Is Family Legal Protection Required?	Please Choose Yes No