Surname	A value is required.	Forenames		Title	Mr Mrs Miss
Company Name		Occupation			-Employment Status- Employed Self Employed Household Duties Education Retired Unemployed

Telephone	A value is required.	Email	A value is required.Invalid format.
Address of Property to be insured		Postcode	A value is required.

Property Details	-Type of Property- Private House Block of flats/apartments Retail Premises Commercial/Industrial Warehousing Other please specify
	Is the building listed? No Yes -Roof Construction- Slate Tile Timber Felt Thatch -Wall Construction- Brick Concrete Stone Wood Other Year Property Built

Covers Required	-Please Select- Contents Only Buildings Only Buildings and Contents	Buildings Sum Insured
		What is the total value of your contents?
		Highest Value any one item
Have you had any losses in the last 5 years?	No Yes Provide Details

Do you have good quality security locks on all external doors and windows?	Please Choose Yes No	Do you have an intruder alarm installed?	Please Choose Yes No
Do you have smoke detectors?	Please Choose Yes No	Is the Property Boarded Up?	Please Choose Yes No
Is the property undergoing refurbishment to the external fabric of the building?		Please Choose Yes No
Correspondence Address		Postcode
Please give details of any other factors that might influence an insurance company in their assessment of this risk or any other comments you feel may be important.