Surname Forenames Title
Date of Birth   

   
Occupation      
Telephone Email    
Address of Property to be insured      
  Postcode    
Reason for Unoccupancy Year Property Built Covers Required
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?   
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?
Is the Property Boarded Up? Is the property undergoing refurbishment to the external fabric of the building?