Home Insurance

1. Name of Brokerage/Agent:
2. Contact Name:
3. E-mail address:
4. Telephone Number:

1. Title: Mr Mrs Miss Ms Dr Sir
   Forename:
2. Surname:
3. Date of Birth:
4. Occupation:
5. Employers Business:
6. Cover Start Date:
7. Name of Existing Insurer (if any):
8. How many years has the Insured been claim free? 0 1 2 3 4 5 6 7 8 9+
9. Please confirm reason for Risk Being Non Standard:

1. Postcode of Property to be Insured:
2. Risk Type: Owner Occupied Tenants Contents (If Tenants Contents, Buildings Cover is not available)
3. Number of Bedrooms:
4. Is the Property Alarmed? YES NO
5. If Yes Please confirm Type, Signalling etc.:

1. Buildings sum insured: (Excluding outbuildings)
2. Outbuildings sum insured:
3. Total Buildings Sum Insured:
4. Is Accidental Damage Cover Required: YES NO
5. Excess Required: £100 £250 £500 £1000 £2500 £5000
6. Building Type: Bungalow Detached Bungalow Semi Detached Bungalow Terraced House Detached House Semi Detached House Terraced Flat Basement Flat Ground Floor Flat Other
7. Year of Build:
8. Listed Building: Not Listed Grade 1 England/Wales Grade 2* England/Wales Grade 2 England/Wales Grade A Scotland Grade B Scotland Grade C Scotland Grade A Northern Ireland Grade B+ Northern Ireland Grade B Northern Ireland
9. Wall Construction: Brick Asbestos Brick on Timber Frame Cob Concrete Corrugated Iron Essex Fibreglass Flint Glass Metal Plastic Pre-Fabricated Stone Stramit Timber & Plastic Timber Framed Timber Wattle & Daub Wood Other
10. Roof Construction: Tiled Asbestos Asphalt (<33%) Asphalt (>33%) Concrete Corrugated Iron Felt on Timber (<33%) Felt on Timber (>33%) Fibreglass Glass Metal Plastic Shingle Slate Stramit Thatched (Fibre) Thatched (Reed) Timber Turnerised Woodwork Other
11. Excluding Subsidence/Heave/Landslip: YES NO

1. General Contents sum insured:
2. Excess Required: £100 £250 £500 £1000 £2500 £5000
3. Is Accidental Damage Cover Required: YES NO

1. Jewellery:
2. Furs:
3. Personal Possessions:
4. Gold /Silver (Inc. Plate):
5. Pictures:
6. Guns:
7. Jewellery in Bank:

1. Domestic Freezer Cover:
2. Pedal Cycles:
3. Money:
4. Credit Cards:

If this is not correct please supply full details in the box below the statements to enable us to consider acceptance/terms.

The Policyholder or any other person living with him/her

• have never been convicted of or charged with any offence (other than motoring offences)
• have never been made bankrupt or entered into a bad debt arrangement with creditors
• have never had insurance cancelled, refused, declined or voided
• Has not sustained any loss or damage during the last 5 years which would have been covered under this insurance , whether claimed or not?

The Home

• Is in a good state of repair and regularly maintained
• Is built in an area historically free from flooding and coastal or river erosion and not within 200 metres of any river, stream or tidal waters
• Is free from signs of internal or external stepped or diagonal cracking
• Is not being monitored for subsidence, heave or landslip; has never been monitored for subsidence, heave or landslip, or suffered from subsidence, heave or landslip
• Has not had a survey carried out on it which mentions subsidence, settlement or movement of the buildings
• Has no neighboring buildings that have been the subject of an occurrence of subsidence, heave or landslip
• Has no trees or shrubs within 7 meters (22 feet) of your home (whether inside or outside the premises which are more than 3 meters (10ft) tall)
• Has no building works in progress or planned in the next 12 months
• Is the Policyholders main and permanent place of residence
• Is not used for any business, trade or profession
• Is not regularly left unattended other than during daytime working hours
• Is not left unoccupied for periods in excess of 60 consecutive days

Security

• Final exit doors are secured by mortice deadlocks with at least 5 levers or a rim deadlock confirming to British Standard 3621 or, if the door(s) are UPVC or double glazed, a multi-point locking system with either a lever or built-in deadlocking cylinder

If the above is not the case then please give details:

Notes (Should you wish to advise of any additional information please give details)

1. Target Premium: