Please complete all the mandatory fields marked with an *
* Title
* First Name
* Surname
* Address
* Telephone
Mobile
* Email
Method Of Contact

Company Name
Company Registration Number
Business Description
Date Established:

Occupation
Risk Address (if different)
Clients date of birth
Year property was built
Number of bedrooms
Buildings Sum Insured	£
Contents Sum Insured	£
Rent Sum Insured	£
Inception Date
GENERAL QUESTIONS - If you answer no to any of the questions, please provide the additional details in the continuation box at the end of the form.
1. Is the dwelling
(a) built of brick, stone or concrete	Yes No
(b) roofed with slates, tiles, metal, asphalt or concrete	Yes No
2.
(a) Is the dwelling used for any business purposes or	Yes No
(b) Does the dwelling adjoin any business premises	Yes No
3. Is the dwelling in a good state of repair and will it be so maintained	Yes No
4. Have you, or any member of your family permanently residing with you
(a) an insurance policy in force covering any of the events against which you wish to insure	Yes No
(b) ever suffered a loss from any of the events against which you wish to insure	Yes No
(c) ever been refused insurance or had special terms imposed by any insurer in respect of any of the events against which you wish to insure	Yes No
5. Are all external doors of solid wood and fitted with at least one mortise deadlock	Yes No
6.
(a) Is the dwelling particularly exposed to storm or flood damage	Yes No
(b) Has there been any history of flood damage in the immediate area	Yes No
7 Type of property.
(a) House	Yes No
(b) House converted into flats	Yes No
(c) Other	Yes No
8. Is the dwelling
(a) currently unoccupied	Yes No
(b) free from any signs of damage by subsidence, heave or landslip with no cracks in external walls and no history of damage by these events	Yes No
(c) in an area where neighbouring properties are free from damage by subsidence heave or landslip with no cracks in external walls with no history of damage by these events	Yes No
9. Is the dwelling let to
(a) Working People	Yes No
(b) Students	Yes No
(c) DSS / Council	Yes No
(d) Housing Association	Yes No
10. Are there any cooking facilities in the bedrooms	Yes No
11. Please give the name and address of any interest in the buildings (e.g. Mortgage Lender) which should be noted in the policy
continuation area for additional comments in response to 'no' answers:
To the best of my knowledge I believe the information given to be true and correct.