Title	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
Occupation		-Employment Status- Employed Self Employed Household Duties Education Retired Unemployed
Telephone		Mobile Phone
Address of Property 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 Is the building listed? No Yes -Wall Construction- Brick Concrete Stone Wood Other -Bedrooms- One Two Three Four Five Six Over Six
Reason for Unoccupancy
Year Property Built
Covers Required	-Please Select- Contents Only Buildings Only Buildings and Contents
Buildings Sum Insured		Rebuilding Cost not market value.
What is the total value of your contents?
Highest Value any one item
Have you;
Have you had any losses in the last 5 years?    No Yes
Do you have good quality security locks on all external doors and windows?	Please Choose Yes No quotes are subject to basic minimum security standards
Do you have an intruder alarm installed?	Please Choose Yes No
Do you have smoke detectors?	Please Choose Yes No
Is the Property Boarded Up?	Please Choose Yes No
Is the property undergoing refurbishment to the external fabric of the building?		Please Choose Yes No