Name:

E-mail address:

House Number:

Postcode:

Daytime Telephone No:

Renewal Date:

Occupation:

Property Type: (eg flat, terraced, semi-detached):

Year Built:

Listed Building? Please Choose Yes No

Standard Construction? Please Choose Yes No

Do You Work From Home? Please Choose Yes No

Any Criminal Convictions? Please Choose Yes No

Any Previous claims? Please give details

Insurance Ever Refused? Please Choose Yes No

Any Previous Subsidence? Please Choose Yes No

Do You Have Doors & Window Locks? Please Choose Yes No

Are you a member of a Neighbourhood Watch Scheme? Please Choose Yes No

Do you have an alarm (please state model)?

Building Sum Insured:

Accidental Damage? Please Choose Yes No

Contents Sum Insured:

Unspecified Personal Belongings Sum Insured?

Single Valuables Over £1500. Please list: