| Name | |
| Address | |
| Phone No. | |
| Email | |
| Age of proposer/Spouse | |
| How many smoke detectors have you | |
| Is your home built of stone/concrete and roofed with tiles/slates | YesNo |
| What percentage of the total roof is timber, felt, etc | |
| In what year was your house built | |
| How many bedrooms in your house | |
| Is your house alarmed to IS199 | YesNo |
| If so, have you an annual maintenance contract on the alarm | YesNo |
| Is it linked into a central monitoring station | YesNo |
| Is your house regularly occupied during the daytime | YesNo |
| Are you a member of a Neighbourhood Watch Scheme or Community Alert Scheme | YesNo |
| What is the name of your present motor insurance company | |
| Have you had any household claims in the past 5 years | YesNo |
| If yes, please fill in the following: | |
| Date | |
| Type of claim | |
| Cost of claim | |
| Sum to be insured on Buildings | |
| Sum to be insured on Contents | |
| Do you require All Risks Cover | YesNo |
| If so, please give details | |
| Do you require Standard or Accidental Damage Cover | |
| Are paying guests kept | YesNo |
| If so, how many | |
| Is any part of building used for business purposes, ie. office, surgery, child minding etc. | YesNo |
| If so, please give details | |
| Date of application | |
Whilst we take all reasonable care in preparing quotations, a quotation can only be confirmed by the Insurance Company on reciept of all appropriate documents.
