Name
Address of Property
Address
Address			Postcode
Telephone Number			Fax Number
Email Address			Occupation
Date of Birth
Year Built   Listed Property Grade I Grade II Two Star No Good State of Repair Yes No Last Electrical Inspection 1 Year 2 Years 3 Years 4 Years 5 Years Over 5 Years Percentage Thatch Roof 100% 90% 75% 50% 25% 10%
Wall Construction        Type of Thatch Water Reed Long Straw Combed Wheat Devon Wheat Reed Norfolk Reed Nature of Property Permanent Home Holiday Home - Not let Holiday Home - Let Weekend Home Other
Date rethatched      Last inspected by thatcher Number of Open Fires 0 1 2 3 4 5
Woodburning stoves Yes No Multifuel Stove Yes No Chimneys Swept Annually Yes No Are the Chimneys Lined Yes No
Is the chimney at least 1m above thatched roof?   Please Choose Yes No
Is a Spark Arrestor fitted to chimney?   Please Choose Yes No Are at least 2 fire extinguishers in place one in kitchen?   Please Choose Yes No
Room Treated with fire retardant?   Please Choose Yes No
Building Sums Insured
Contents Sums Insured
Jewellery/Personal Effects sum insured
Personal Money
Pedal Cycles
Is the property fitted with mortice dead locks on the final exit doors?		Please Choose Yes No
Neighbourhood Watch member?		Please Choose Yes No
Have you had any losses or made any claims in the last three years?		Please Choose Yes No if yes please provide details
Has the property/area a history of storm, flood, subsidence, landslip or heave?		Please Choose Yes No if yes please provide details
Ever been refused cover or has additional terms applied by your insurer?		Please Choose Yes No if yes please provide details
Key operated window locks on all accessible windows?	Please Choose Yes No
Do you have a NACOSS/SSAIB Approved Alarm?	Please Choose Yes No
Previous Convictions?	Please Choose Yes No if yes please provide details
Is Family Legal Protection Required?	Please Choose Yes No