Your Name*:

Your Phone*:

Your Email*:

Address*:

Any Claims in Past 5 Years*: ---YesNo

If So, Give Details:

Is the Property of Standard Construction?*: ---YesNo
Private House must be of standard construction - constructed of brick, stone or concrete and roofed substantially (at least 70%) with slates, tiles, metal, concrete or asphalt

If No, Give Details:

Is this Your Primary Residence?*: ---YesNo
Private house must be occupied for residential purposes only and in good repair and so maintained. Private house be the principal residence

If No, Give Details:

Do You Operate a Business from Home?*: ---YesNo

If Yes, Give Details:

Is Your Property Solely Occupied by Yourself and Your Family?*: ---YesNo

If No, Give Details:

Buildings Sum Ins*:

Contents Sum Ins*:

Any Other Specific Items*:
(e.g. Jewellery, Caravans, Mobile Homes, Sports Equipment etc.)

Age Of House*:

Burglar Alarm*: ---YesNo

Security Code*: