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Customer in Office
The following details have been captured by one of our brokers with you.
Broker Name
Time Captured
Date Captured
HOME INSURANCE
Title
Please Select
Mr
Ms
Mrs
Bishop
Br
Dean
Doctor
Fr.
Miss
Other
Prof
Rev
Sister
Sr
Unknown
Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Phone Number
*
Your Date of Birth
*
-
Day
-
Month
Year
Date
Full Time Occupation
*
Employment Status
*
Please Select
Employed
Household Duties
Retired
Self Employed
Unemployed
Company Director
Independent Means
Student
Voluntary Work
Smoker
*
Please Select
No
Yes
First Time Buyer
*
Please Select
No
Yes
Main Proposer
*
Please Select
No
Yes
Do you need the policy in Joint Names?
*
Please Select
No
Yes
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Additional Named Person Details
Additional Name Title
*
Please Select
Mr
Ms
Mrs
Bishop
Br
Dean
Doctor
Fr.
Miss
Other
Prof
Rev
Sister
Sr
Unknown
Additional Name
*
Additional Name Date of Birth
*
Additional Name Full Time Occupation
*
Additional Name Employment Status
*
Please Select
Employed
Household Duties
Retired
Self Employed
Unemployed
Company Director
Independent Means
Student
Voluntary Work
Additional Name Smoker
*
Please Select
No
Yes
Additional Name First Time Buyer
*
Please Select
No
Yes
Additional Name Main Proposer
*
Please Select
No
Yes
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Your Postal Address
*
Address Line 1
Address Line 2
City/Town
County
Eircode
Is the postal address the address of the property you wish to insure?
*
Yes
No
Risk Address
Address Line 1
Address Line 2
City/Town
County
Eircode
Property Type
*
Please Select
Bungalow
Country Mansion
Detached House
Farm House
Flat
Maisonette
Purpose Built Apartment
Semi Detached House
Terraced House
Year Property Built
*
Is the property a listed building?
*
Please Select
No
Yes
Is there a basement in the property?
*
Please Select
No
Yes
Roof Construction
*
Please Select
100% Standard
Not Listed
Asbestos
Asphalt
Corrugated Iron
Felt on Timber
Fibreglass
Glass
Metal
Plastic
Shingle
Stramit
Thatch Fibre
Thatch reed
Timber
Turnerised
Woodwork Construction
If 'Not Listed' Please advise more details
Any part of the property flat roof or non standard construction?
*
Please Select
No
Yes
Please State Percentage of Non Standard Area (as a % of the overall building area)
*
Please advise details of flat or non standard roof
Are there any members of your household that smoke?
*
Yes
No
What is the total square footage of your house?
*
Do you have a seperate Garage to the main Property?
*
Please Select
No
Yes
What is the total square footage of your garage?
*
how many acres the property is set on?
Number of Bedrooms
*
Number of Bathrooms
*
Standard Door & Key Operated Window Locks?
*
Please Select
No
Yes
Type of Alarm on the Property
*
Please Select
None
PSA / NSAI Approved Installer to EN50131 Standard to Central Station
PSA / NSAI Approved Installer to EN50131 Not Connected to Central Station
Installed to EN50131 standard to Central Station
Installed to EN50131 standard Not Connected to Central Station
Other
Number of Smoke alarms
*
Type of Heating System in the Property
*
Please Select
Electric
Gas
Heat Exchange unit
Mixture Including Oil
Oil
Solar / Wind
Solid Fuel
Unknown
Wood / Wood Pellets
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Residence Type
*
Please Select
Owner Occupied
Main Residence - Awaiting Occupancy
Unoccupied
Course Of Construction
Rented - 1 Person
Rented - 10 People
Rented - 2 People
Rented - 3 People
Rented - 4 People
Rented - 5 People
Rented - 6 People
Rented - 7 People
Rented - 8 People
Rented - 9 People
Rented -Couple
Rented - Family
Rented - Students
Under Renovation
Unspecified
Main Proposer Landlord or Tenant?
Please Select
Landlord
Tenant
Let more than 5 times per year
*
Please Select
No
Yes
Property Furnished?
*
Please Select
No
Yes
Do you rent out any rooms of have any paying guests?
No
Yes
Please state number of Paying guests
Normal Day Time Occupancy
*
Please Select
No
Yes
Do You or any of member of the household work from home (full or partime capacity)
*
Please Select
No
Yes
If Yes, would people be calling to the property in respect of this work?
*
Please Select
No
Yes
If Yes, does your employer or do you have a seperate liability policy in place covering you in respect of customers/clients calling to your home?
*
Please Select
No
Yes
Neighbourhood Watch / Community Alert
*
Please Select
No
Yes
Number of years at this address?
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Cover required from?
-
Day
-
Month
Year
Date
Amount of buildings cover required €
*
The Rebuilding Amount - Not the Market Value
Amount of home contents cover required €
*
Do you require accidental damage cover on your buildings and contents Insurance?
*
Please Select
Yes
No
Do you require cover for All Risks for specified or unspecified Items?
*
Please Select
Yes
No
Total amount of unspecified All Risks €
List Amount of Specified Items and value for each Item €
Confirm last valuation date for any items above
Do you have Solar Panels Installed?
*
No
Yes
Were they installed by an approved registered Installer?
No
Yes
Do you have PV Battery Storage?
No
Yes
Where are the panels installed?
Roof, Ground Level, etc
Total Value of the system? €
Any Garden Shed(s), Garage(s) or Outbuilding(s) on your property?
*
Please Select
Yes
No
Details of any Garden Shed(s), Garage(s) or Outbuilding(s) Structure
What year was it built
Total size (Square Ft or M) please state
Type of Use for the Garden Shed(s), Garage(s) or Outbuilding(s)
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Currently / Previously Insured?
*
Yes
No
Name of existing Home Insurer
*
Your Home Renewal date
-
Day
-
Month
Year
Date
Number of years claims free
Any claims you have made in the last 5 years on this or any other property
*
Please Select
Yes
No
Please give details of any claims you have made in the last 5 years on this or any other property
Who are your private car insurers?
Any Other Information
Where did you hear about us
*
Please Select
Existing Customer
Past Customer
Word of Mouth
Radio Ad
Facebook
LinkedIn
Email
Google Search
Other
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Year
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