Home Insurance Application Form

Please take a few moments to complete the form below.

If you have any questions, call us on 01624 832042.

Date Cover Required From:

Personal Info

Title:
Surname:
Forenames:
Sex:
Date of Birth:
Marital Status:
Occupation:
Employers Business Type:
Contact Tel Number(s):
Email Address:: If you provide a contact email address we will email you confirmation when you submit this form

Your Property

Post Code:
Address:
Property Type:
Approx. age of building:
Type of construction:
If not standard, please give details:
Any building work in progress?
If yes, please give details:
Number of bedrooms:
Is it a holiday home?
Is it owned or rented?
Are you a first time buyer?
Is it let or sub-let?
Is it used for business?
If yes, describe nature of business:
Are all windows fitted with key operated locks?
Do you have an alarm installed?
Are smoke detectors installed?
Is the building in a good state of repair?

Previously…

Has the building ever been flooded?
Is the building in a flood area?
If yes, please give details:
Have you previously had buildings insurance?
If yes, who was your insurer:
Have you previously had contents insurance?
If yes, who was your insurer:

Years since your last claim:
How many claims in the last five years:: Fill in any details below.

Claim 1

Details of the claim:
Date of claim:
Amount of payment received:

Claim 2

Details of the claim:
Date of claim:
Amount of payment received:

Claim 3

Details of the claim:
Date of claim:
Amount of payment received:

Cover Details

Do you require buildings cover?
If yes, specify rebuild cost:
Do you require contents cover?
If yes, specify replacement value:
Any cycles over £500?
If yes, please provide details:
Any single item of Jewellery/watches/laptops over £2,000?: If YES, for security purposes, please call us on 832042 with the details after submitting this form.

Do you have an alternate address for correspondence?

Correspondence Address

Post Code:
Address:

I confirm that all persons named including myself have no criminal convictions or have ever been refused insurance:

Submit this form to us and we will get back to you as soon as we can with a quote. If you have provided your email address you will receive email confirmation. If you require any help, please call us on 01624 832042.