Proposer			Required if Joint Names
Title	Mr Mrs Miss			Mr Mrs Miss
Forenames
Surname
Date of Birth   dd/mm/yyyy
	- Sex - Male Female Marital Status Single Married Common Law Divorced Separated Partnered Widowed N/A			- Sex - Male Female Marital Status Single Married Common Law Divorced Separated Partnered Widowed N/A
Occupation
	-Employment Status- Employed Self Employed Household Duties Education Retired Unemployed			-Employment Status- Employed Self Employed Household Duties Education Retired Unemployed
Telephone
-No Claims Bonus- 5+ Years 4+ Years 3+ Years 2+ Years 1+ Years Nil Years	Previous Insurer			Renewal Date
Address to be insured.
Postcode
Email
-Type of Property- Detached House Semi Detached House Terraced/Town House Detached Bungalow Semi Detached Bungalow Self Contained Flat Maisonette	-Roof Construction- Slate Tile Timber Felt Thatch			% Felt Roof None Less than 10% Less than 20% Less than 30% Less than 40% Less than 50% More than 50%
-Wall Construction- Brick Concrete Stone Wood Other	Year Property Built			-Bedrooms- One Two Three Four Five Six Over Six
Covers Required	-Please Select- Contents Only Buildings Only Buildings and Contents			-Please Select- Standard + Accidental Damage Standard Cover
Buildings Sum Insured	Rebuilding Cost			Accidental Damage Cover No Yes
What is the total value of your contents?				Accidental Damage Cover No Yes
Highest Value any one item >£1500		Total value of items over £1500
All Risks Cover	Freezer Contents
	Bicycles
Do you require cover for property outside the home?	No £2000 £2500 £3000 £3500 £4000 £4500 £5000
Have you had any losses in the last 5 years?	No Yes
-Ownership Status- Owned by Proposer Owned by Local Authority Owned by Landlord Owned-Let Furnished Owned-Let Unfurnished	Mortgage Provider if applicable			-Occupancy- Permanent Residence Holiday Home Let to Others Weekend Home Weekday Home
Are the premises usually occupied during the day?	Yes No Not Answered		Are the premises usually occupied during the night?		Yes No Not Answered
Do you have good quality security locks on all external doors and windows?	Yes No Not Answered		Do you have an intruder alarm installed?		Yes No Not Answered
Do you have smoke detectors?	Yes No Not Answered		Are you a member of a Neighbourhood Watch Scheme?		Yes No Not Answered
Has the property ever experienced	Flooding No Yes Ground Heave No Yes Landslip No Yes Subsidence No Yes
Is the property within 400 metres of a river or cliff?	No Yes
Do you have any other comments that may be relevant?