Fields marked * are compulsory

* Name:

* Contact Telephone Number:

* Contact Email Address:

* Date of Birth:

* Occupation:

* Risk address:

* Postcode:

Alternative correspondence address:

* Year built:

* Listed building?
Yes    No

* Property type (eg. detached, semi-detached etc.):

* Construction (eg. brick walls / tiled roof):

Main Building sum insured:

Outbuildings sum insured:

Building Cover required?
Standard    Accidental damage

Preferred Buildings excess?
£50    £100    £250

General Contents sum insured:

Contents Cover required:
Standard    Accidental damage

Preferred Contents excess?
£50    £100    £250

All risks - min. £2000:

Specified items over £1000:

* Are all buildings in good state of repair?
Yes    No

* Has the property any history of flooding?
Yes    No

* Has the property any history of subsidence, heave or landslip?
Yes    No

* Is the property due, or undergoing, renovations?
Yes    No

* Minimum security - 5 lever and key operated window locks?
Yes    No

* Does the property have a burglar alarm?
Yes    No

Previous Insurer:

Renewal date:

Renewal premium:

Special terms:

Details of any claims in the last five years:

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