From what date is cover required?
*
/
Day
/
Month
Year
Title
*
Please Select
Dr
Miss
Mr
Mrs
Prof
Rev'd
Name
*
First name
Last name
Date of birth
*
/
Day
/
Month
Year
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
Address of property to be insured
*
Street address
Address line 2
City
Region
Postcode
What year was the property built?
*
Type of property?
*
House
Bungalow
Flat
Mid-terrace
End terrace
Maisonette
Other
Type of building?
*
Detached
Semi-detached
Linked
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
*
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
Do you require cover for your buildings?
*
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
Please state the replacement value
Please provide a brief description
Do you require family legal protection cover?
*
Yes
No
How long have you held your own home insurance?
*
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?
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 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
SUBMIT
Should be Empty: