Home Insurance - Quotation Details
Code (For Office Use Only)
Details taken by
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Niall
Amanda
Mark
Sharon
Gerry
Ann Marie
Phone or Counter Call
Phone
Customer in the Office
Date
/
Day
/
Month
Year
Date
Hour Minutes
Policy Holders Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
Date Of Birth
Occupation
Do you require the policy to be in joint names?
*
Yes
No
Additional Policy Holder
First Name
Last Name
Date Of Birth
Occupation
Is there any business carried out from the premises?
*
Yes
No
Is there a seperate entrance & exit in place for this business? Give full Details
Postal Address
*
Address Line 1
Address Line 2
City/Town
County
Eircode
Do you live in the property or are you renting out
*
Please Select
Owner Occupied
Rented
Is the Risk Address of the property different
*
Please Select
Yes
No
Risk Address
Address Line 1
Address Line 2
City/Town
County
Eircode
Buildings Sum Insured
*
Rebuild cost of the property
Contents Sum Insured
*
Contents of the property
Specified items details
Rows
Item Description
Item Value
Item 1
Item 2
Item 3
Item 4
Do you require any high value items specified
*
Please Select
Yes
No
ex: High value Jewelry
What year was the property built
*
ex: 1945
Is your premises (and outbuildings) made of standard construction, roof being slate/tile/asphalt and walls as brick/stone/concrete
*
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Yes
No
If your premises is not standard construction as above please give full details below
Is your premises
*
Please Select
Detached
Semi Detached
End of Terrace
Mid Terrace
Duplex
Other
What percentage of the roof on the premises is flat
*
If no flat roof input 0
Number of Bedrooms
*
ex: 4
Number of Bathrooms
*
ex: 2
Is there 5 lever locks on all external doors
*
Please Select
Yes
No
Is there Key/Push Button locks on all windows
*
Please Select
Yes
No
Is there 2 or more smoke alarms in the premises
*
Please Select
Yes
No
Is there a Burglar Alarm fitted to the premises
*
Please Select
Yes
No
Is the alarm
Bell Alarm only
Monitored Alarm (Phonewatch or Phone Notification)
How is the premises heated
*
Please Select
Oil
Gas
Electric
Wood Pellet
Mixed Fuel
Number of years living at the premises
*
Has there been any claims within the last 5 years at this premises
*
Please Select
Yes
No
If yes please give full details of all claims
How many years claims free do you have at this premises
*
ex: premises insured for 10 years consecutively with no claims
Current insurer name
*
ex: Zurich
Renewal Date
*
/
Day
/
Month
Year
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In order to obtain you a quotation we need your permission to submit your details provided to insurers to obtain you a quotation
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Contact Preference
Please confirm we can contact you by email, telephone, SMS or post with quotations or in respect of any policy you hold with us
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Email
Telephone
Post
Text Message
Marketing Consent
From time to time we may also send you communication in relation to other products or services we offer. We never share your email address with any other parties. Please confirm that it is OK to send you marketing information from National Insurance. Please choose below
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