Please complete all the details required below Personal Details First Name / Last Name   Address of property to be insured Postcode When is your policy due? 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1   December November October September August July June May April March February January What is your best quote to date? £ Which insurance company quoted this? What is the excess they are quoting? none £50 £100 £200 £250 £300 £350 £400 £500 Daytime Telephone Number Evening Telephone Number e-mail Address Preferred Contact Method email Telephone (Daytime) Post (if other or recommended source please state who) Your Date of birth Your Job Title Industry worked in Are you a first time buyer? . Yes No Is anyone in the family a smoker? . Yes No Enter the number of claims/losses made in the last five years? 0 1 2 3 4+ *Please also include losses where you have not claimed Please list any claims/losses below including date, brief circumstances and cost:   Type of Property Type of property? Detached House Semi-Detatched House Detatched Bungalow Mid-Terrace House End-Terrace House Purpose Built Flat Other: Please state below When was your property built? How many bedrooms? 1 2 3 4 5 6+ Buildings Sum Insured £ Does this represent the total rebuild cost including debris removal and solicitors fees? . Yes No   Cover Required Buildings Insurance Cover Required None Standard perils+subsidence Standard perils+subsidence+accidental Damage Buildings Excess Required none N/A £50 £100 £200 £250 £300 £350 £400 £500 How many years claim free have you been on Buildings? N/A have not had buildings before 1 2 3 4 5 6+ Total Contents Sum Insured £ Valuables Sum Insured £ Contents Insurance Cover Required None Standard perils excluding accidental damage Standard perils including accidental damage Contents Excess Required none N/A £50 £100 £200 £250 £300 £350 £400 £500 How many years claim free have you been on Contents? N/A have not had contents before 1 2 3 4 5 6+ Does your contents sum insured represent the full replacement value of your contents? . Yes No Construction of wall . Asbestos Brick Brick/Timber Frame Cob Concrete Corrugated Iron Essex Fibreglass Flint Glass Metal Plastic Prefabricated Building combustable materials Prefabricated non conbustable materials Stone Stramit Timber Timber/Plaster Timber frame Wattle & Daub Woodwork Woodwall Other Construction of roof . Asbestos Concrete Corrugated Iron Felt on Timber Fibreglass Glass Metal Plastic Shingle Slate Stone Stramit Thatch Reed Thatch Fibre Tile Timber Turnerised Woodwork construction Other What percentage of your roof is flat? . 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100% If any of your roof is flat, when was the last time it was renewed? N/A no flat roof 12 months 3 years 5 years 10 years Don't know Is the home together with the surrounding area free from any signs of damage by landslip subsidence or heave? . Yes No * If no we will need to contact you to discuss Is your home free from any previous underpinning or any remedial action due to subsidence, heave, landslip or erosion. . Yes No * If no we will need to contact you to discuss Is the home in an area free from flooding? . Yes No * If no we will need to contact you to discuss Is the home within 250 metres of a cliff, river bank, lake, seafront, reservoir, quarry or other excavation? . Yes No * If yes we will need to contact you to discuss Are there any trees or shrubs within 7 metres of the property which are more than 5 metres tall? . Yes No * If yes we will need to contact you to discuss Will your property ever be unoccupied? . No - I do not work but may occasionally go out No - my spouse is at home Yes - during the day but not for more than 30 consecutive days Yes - For more than 30 consecutive days at a time Do you require cover for items to be taken away from the home? (personal possessions or all risks)   Sports equipment? Not insured £100 £200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £2000 £2500 £3000 £3500 £4000 £4500 £5000 Furs? Not insured £100 £200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £2000 £2500 £3000 £3500 £4000 £4500 £5000 Photo equipment? Not insured £100 £200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £2000 £2500 £3000 £3500 £4000 £4500 £5000 Valuables? Not insured £100 £200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £2000 £2500 £3000 £3500 £4000 £4500 £5000 Personal Effects? Not insured £100 £200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £2000 £2500 £3000 £3500 £4000 £4500 £5000 Pedal Cycles? Not insured £100 £200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £2000 £2500 £3000 £3500 £4000 £4500 £5000 Please list here any items that you wish to cover that are themselves valued at more than £1000.  For pedal cycles please list any over £250: Do you require cover for:   Frozen food? Not insured £100 £200 £300 £400 £500 £600 £700 £800 £900 £1000 Money? Not insured £100 £200 £300 £400 £500 £600 £700 £800 £900 £1000 Credit cards? Not insured £100 £200 £300 £400 £500 £600 £700 £800 £900 £1000   Security Does your property have BS3621 locks on all external doors? . Yes No Does your property have key operated locks fitted to all accessible windows and patio doors? . Yes No Does your property have an alarm? . No Yes - DIY install Yes - NACOSS/SSAIB Bells only with maintainence Yes - NACOSS/SSAIB Bells only WITHOUT maintainence Yes - NACOSS/SSAIB Central station with maintainence Yes - NACOSS/SSAIB Central station WITHOUT maintainence Yes - NACOSS/SSAIB Redcare WITHOUT Maintainence Yes - NACOSS/SSAIB Redcare with Maintainence Are you a member of an approved neighbourhood watch scheme? . Yes No Is the property fitted with a BSI approved Smoke detector and is functional? . Yes No   Underwriting Questions: (must be completed in all cases) Ownership type . Owned on mortgage by proposer/spouse not let Owned on mortgage by proposer/spouse and let Owned outright by proposer/spouse and not let Owned outright by proposer/spouse and let Rented from local authority/housing association Rented from private landlord Occupancy status . Permanent home by myself and my family Let to professional people Let to DSS Let to Students Let to Assylm seekers Holiday home Weekday home Weekend home Is the home occupied solely by you and your family as a permanent residence? . Yes No Is there any business use at the property? . No Yes - clerical only with no visitors Yes - clerical only with very occasional visitors (i.e. Taxman) Yes - Light industrial use no visitors Yes - industrial use with visitors to premise Yes - consultancy/advice use with visitors Is your property a listed building? . Not Listed Grade 1 listed building Grade 2 listed building Preservation order Have you or anyone living with you ever been convicted or arson, theft or any offence other than driving offences? (Convictions regarded as spent by virtue of the Rehabilitation of Offenders Act 1974 need not be disclosed) . Yes No * If yes we will need to contact you to discuss Have you or anyone usually living with you ever had any financial or legal problems such as Bankruptcy, Liquidation or CCJ's? . Yes No * If yes we will need to contact you to discuss Have you or anyone living with you had any previous insurance subjected to increased terms, conditions, withdrawn or refused? . Yes No * If yes we will need to contact you to discuss Is the home self contained with a separate lockable entrance door under your sole control? . Yes No * If no we will need to contact you to discuss

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FSA Reference number is 450429

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