From what date should your policy commence?
*
/
Day
/
Month
Year
Title
*
Please Select
Dr
Miss
Mr
Mrs
Prof
Rev'd
Name
*
First name
Last name
Date of birth
*
/
Day
/
Month
Year
Full postal address
*
Street address
Address line 2
City
Region
Postcode
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Occupation
*
Is a joint policy required?
*
Yes
No
Title
*
Please Select
Dr
Miss
Mr
Mrs
Prof
Rev'd
Name
*
First name
Last name
Date of birth
*
/
Day
/
Month
Year
Please state relationship to the main proposer
*
Do you have any lodgers?
*
Yes
No
Do any others over the age of 16 live at the property?
*
Yes
No
Title
*
Please Select
Dr
Miss
Mr
Mrs
Prof
Rev'd
Name
*
First name
Last name
Date of birth
*
/
Day
/
Month
Year
Please state occupation
*
Please state relationship to the main proposer
*
Do any others over the age of 16 live at the property?
*
Yes
No
Title
*
Please Select
Dr
Miss
Mr
Mrs
Prof
Rev'd
Name
*
First name
Last name
Date of birth
*
/
Day
/
Month
Year
Please state occupation
*
Please state relationship to the main proposer
*
Do any others over the age of 16 live at the property?
*
Yes
No
Title
*
Please Select
Dr
Miss
Mr
Mrs
Prof
Rev'd
Name
*
First name
Last name
Date of birth
*
/
Day
/
Month
Year
Please state occupation
*
Please state relationship to the main proposer
*
Do any others over the age of 16 live at the property?
*
Yes
No
Title
*
Please Select
Dr
Miss
Mr
Mrs
Prof
Rev'd
Name
*
First name
Last name
Date of birth
*
/
Day
/
Month
Year
Please state occupation
*
Please state relationship to the main proposer
*
Please confirm your property ownership
*
Please Select
Mortgage
Rented
Owned
Leased
Address of property to be insured
*
Street address
Address line 2
City
Region
Postcode
Is the property a listed building?
*
Yes
No
Is the property your permanent residence?
*
Yes
No
Is the home or land open to the public?
*
Yes
No
Is there any land at the premises that is over 10 acres for which you would like to insure your legal liability to the public?
*
Yes
No
Is the home left unoccupied for more than 30 consecutive days?
*
Yes
No
Current/previous insurer (if applicable)
Annual renewal date (if applicable)
Expiry date of previous insurance (if applicable)
Use of premises to be insured (main home, holiday home, holiday let etc.)
*
What year was the property built?
*
Type of property?
*
House
Bungalow
Flat
Maisonette
Chalet
Maisonette
Other
Type of building?
*
Detached
Semi-detached
Linked
End terrace
Mid-terrace
Other
How many bedrooms do you have?
*
Is the property built of brick or stone with a tile or slate roof?
*
Yes
No
Please provide full details
*
What percentage of the roof is flat?
*
Do all external doors have 5 lever mortice deadlocks and/or a multi-point locking system?
*
Yes
No
Please provide full details
Are all ground floor and accessible windows secured by key-operated window locks?
*
Yes
No
Please provide full details
If your home is protected by an intruder alarm, please indicate which type:
Bells only
Bells with auto-dialler
Central station maintained
Security company monitored
Does your home have a safe?
*
Yes
No
Please provide the model and cash rating
Has the safe been professionally installed?
Yes
Nno
Is it anchored?
Yes
No
Do you have CCTV in operation at the premises?
Yes
No
Do you require cover for your buildings?
*
Yes
No
Is the home and domestic outbuildings in a good state of repair?
Yes
No
Please state the property rebuild value
Do you require cover for the contents within your property?
*
Yes
No
Please state the replacement value
Do you require cover for items taken away from the home?
*
Yes
No
If yes, please select the items which require cover below
Items kept in the bank
Mobile phones
Laptops / Computers
Pedal cycles
Money & credit cards
Unspecified personal possessions & Jewellery (Under £2,500)
If you have selected any of the above, please state the replacement value
Please provide a brief description
If you require cover within the home for valuables and personal belongings with a value of over £7,000, please state these and the value below.
Do you require cover for fine art and antiques
*
Yes
No
If yes, are any items worth over £25,000?
Yes
No
If yes, please detail these here. Please state the value and where they are kept.
Do you require family legal protection cover?
*
Yes
No
How long have you held your own home insurance?
*
Please provide details of any business which is run from the premises.
*
Have you ever made a claim under your home insurance?
*
Yes
No
Please advise the date of the occurence
-
Month
-
Day
Year
Date
What happened?
How much was claimed?
Have you made any additional claims under your home insurance?
Yes
No
Please advise the date of the occurence
-
Month
-
Day
Year
What happened?
How much was claimed?
If any previous losses involved theft from the current premises, please explain how entry was gained and what subsequent precautions have been undertaken to prevent a similar occurrence?
Has the home or its domestic outbuildings suffered from flooding within the last 25 years?
*
Yes
No
Please provide details
Has the home or its domestic outbuildings suffered from or been monitored for subsidence, landslip or heave within the last 25 years?
*
Yes
No
Please provide details
Are you undertaking or planning any extensions, renovations or structural works to your home within the next 12 months?
*
Yes
No
Please provide details
In respect of the proposer or any other person to whom this insurance would apply, has any insurer: declined to accept, cancelled or refused to continue the insurance or agreed to continue the insurance only on special terms?
*
Yes
No
Please provide details
Have you, or any person residing with you, ever been convicted of, or charged with but not yet tried for, any offence other than a driving offence? (subject to the Rehabilitation of Offenders Act 1974)
*
Yes
No
Please provide details
Have you ever been declared bankrupt, insolvent or been subject to an Individual Voluntary Agreement (IVA)?
*
Yes
No
Please provide details
Do you wish to pay an additional excess towards each claim? Please note the standard excess is £100.
*
Yes
No
If yes, please select the additional amount you would like to pay below:
£50
£100
£150
£200
£250
£300
£350
£400
£500
£750
£1000
£2,500
Where did you hear about Cliverton?
*
Please Select
Google
Social Media
Advert
Trade Show
Friend of family referral
Affinity partner
Other
SUBMIT
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