Name
Address
Phone No.
Email
Age of proposer/Spouse
How many smoke detectors have you
Is your home built of stone/concrete and roofed with
tiles/slates Yes
What percentage of the total roof is timber, felt,
etc
In what year was your house built
How many bedrooms in your house
Is your house alarmed to IS199 Yes
If so, have you an annual maintenance contract on
the alarm Yes
Is it linked into a central monitoring station Yes
Is your house regularly occupied during the daytime Yes
Are you a member of a Neighbourhood Watch Scheme or
Community Alert Scheme Yes
What is the name of your present motor insurance
company
Have you had any household claims in the past 5
years Yes
If yes, please fill in the following:
Date
Type of claim
Cost of claim
Sum to be insured on Buildings
Sum to be insured on Contents
Do you require All Risks Cover Yes
If so, please give details
Do you require Standard or Accidental Damage Cover
Are paying guests kept Yes
If so, how many
Is any part of building used for business purposes,
ie. office, surgery, child minding etc. Yes
If so, please give details
Date of application
