HOUSEHOLD INSURANCE PROPOSAL FORM 

Please fully complete the form below and we will respond promptly.

Full Name  
Email Address    
Tele. Number       
Address Line 1    
Address Line 2
Address Line 3  
Post Code      
Date of Birth   
Sex      Female  Male 
Occupation 
              Criminal Convictions ?   YES    NO
              First Time Buyer ?   YES    NO

Property Details

Type of Property ?  
    
Number of Bedrooms:
Standard Construction ?  YES    NO
If No please enter details      
Showing Signs of Subsidence, Ground Heave or Landslip     YES    NO
Security
5 Lever Mortice Deadlocks or Better Fitted?  YES    NO
Key Operated Window Locks ?  YES    NO
Burglar Alarm With Annual Maintenance ?  YES    NO
Building Cover ?  Standard     Accidental Damage
Sum Insured 
Contents Cover ?  New For Old     Accidental Damage
Sum Insured?  
Personal Effects ?  Yes     No
Sum Insured?  
Cover items away from the Home 
Specified Items: (for items valued at more than £1000)  

Details

 Current Value
For the above items, do you have written valuations in the last two years?   YES    NO

Pedal Cycles

 (Cover away from Home)  
How Many: 
Sum Insured: 
Highest Value Bike: 

Money & Credit Cards ? 

(cover up to £500 away from home)      

 YES    NO

Legal Expenses?    

 YES    NO
Any Claims or Losses in the last five years YES    NO
If Yes Please give details with dates and amount claimed: