1. Date of Request: 

2. Name:    Date of Birth

Occupation:


Name of Partner   Date of Birth
(if applicable) 


Partners Occupation:


                                All other persons resident at the risk address. (including children)

Name:    Age    Occupation:     Relationship (to Proposed)

Name:    Age    Occupation:     Relationship (to Proposed)

Name:    Age    Occupation:     Relationship (to Proposed)

Name:    Age    Occupation:     Relationship (to Proposed)

Name:    Age    Occupation:     Relationship (to Proposed)



Email:       Please confirm Email Address: 



4. Risk Address:  

               Town:

            County:

        Postcode:

       Telephone:


        

Correspondence Address if different to above                 

same as above

5.  Correspondence Address:

                                 Town:

                              County:

                          Postcode:



6: Your Occupation:

7.  Lenders Details:       8.  Including A/c Roll No: 



Are the Mortgagee details to be noted Yes No



9. Date of Construction:                                        10. Is the Property Listed  Yes No



11. Type of Construction:                ie. Brick, Stone, Pitched Roof - Standard            
                                                                                                                           Standard Non-Standard  
                                                    Timber Framed, Flat Roof - Non Standard       

Number of Bedrooms:


12. Type of Property   Flat Terrace Semi Detatched                                                   13. Is your Home: Rented Owned Other?




14. Security Approved Locks   Yes No                                                                     Alarm: Yes No

                                                                                                            Maintained Yearly  Yes No

                                                                                                                Central Station:  Yes No





15. Intended Occupancy: Unoccupied Owner Occupied Let      If Unoccupied or Let Give Full Details

                                                                                                        


16. Previous Insurer:




17. Have you been refused insurance or had any terms/or restrictions imposed
at this or any previous home by any insurer:                                                                       Yes No


If No terms are the current insurers aware of the conviction:                                                  Yes No


18. Claims History last 6 Years:

                          Date                            Settled Amount                                        Details

1.                                                              

2.                                                              

3.                                                              


                                                      If more than 3 Please give Details: 




19. Has the Property suffered subsidence or movement of any type?                                         No Yes
      (If yes a survey may be required)


20. Has the property suffered a flood claim?                                                                            No Yes
      (If yes a survey may be required)


If you are unsure about the following questions please leave blank and we will contact you at a later date for the information

21. Is the property within 400m of a watercourse?                                                               Unsure No Yes


Type of Watercourse:                       Distance away from Property:


How High Above  highest Watermark:  

What is between the Property & Watercourse:


22. Are there any trees within the 7 metres of the Property:    No Yes


Type of Tree:                Distance from Property:                  Height: 



23. Have you or any other people residing at  the insured  property ever been
convicted of a criminal offence other than a motoring offences?                                        No Yes




Criminal Convictions  (if more than 3 please provide full details)

Name of person (s) with conviction                                  D.O.B.                                    Occupation

 1.                                                           

 2.                                                           

 3.                                                           



         Date (Month & Year)                                     Sentence and/or Fine                            Served

1.                                                 

2.                                                 

3.                                                 


Details surrounding  each conviction (Please give full explanation for each conviction)

1.       

2.       


3.       





24. Have you ever been declared Bankrupt? (if yes please give full details)                                          Yes No

        Details
       



Building Sum Insured: (min 35,000):       £

Contents Sum Insured (min £15,000)      £

All Risks (min 2,000)                             £

Pedal Cycles                                        £

Money/Credit Cards                               £

Other                                                    £   



25.  Other relevant information:

 

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Broker Details

    Broker Name:                Contact Name:

Broker Address:

               Town:

            County:

               Post:

       Broker Tel:     Fax: