0800 29 88 777
Name:
Date of birth:
House name/number:
Postcode:
*Email:
Occupation:
Have you had any claims under household insurance within the last 5 years ?
Yes
No
If yes, please give details below:
Date
Cost
Policy Type
Circumstances
Year Property Built:
Type of Property:
No. of bedrooms:
Is the property stone/brick built ?
If no, please give details below:
Buildings Sum Insured: £
Is accidental damage cover required ?
Contents Sum Insured: £
Do you require cover for items away from the home ?
If yes, please select from the following:
£1500
£2000
£3000
£5000
Do you have any individual items valued over £1500 which you require cover for away from home?
If you have answered this question yes we will contact you by telephone to confirm these details.
Thank you for providing this information, we will endeavour to contact you within 24 hours with a quotation.
Please note that this form is not a contract and before cover is issued all details must be checked verbally to ensure the information given is accurate.
*Please give your daytime telephone number:
