Your Details
Title	Mr Mrs Miss Ms Dr
Initials
Surname
Date of Birth	/ / (dd/mm/yyyy)
Address
Post Town
County
Postcode
E-mail Address
Telephone (inc. STD)
Occupation
About your property
Type of Property	Detached House Semi Detached House Detached Bungalow Semi Detached Bungalow Detached Cottage Semi Detached Cottage End Terrace Mid Terrace Ground Floor Flat First Floor Flat Second Floor Flat Third Floor Flat Fourth Floor Flat Maisonette Block of Flats Other (specify below)
Other Type of Property
No. of Bedrooms	1 2 3 4 5 6 7 8 9 10+
Year Built
Standard Construction	Yes No
Contents (covers all contents whilst in the house)
Type of Cover	Standard 'New for Old' Standard plus full Accidental Damage
Sum Insured Todays cost of replacing all the contents in your home
All Risks (covers loss of or damage to personal possessions in and away from the home)
All Risks required? (If not required it is not mandatory to fill in the rest of this section)	Required Not Required
Sum Insured for Unspecified Items (Sum insured should represent the maximum amount at risk at any one time)
Sum Insured for those items over £1,000 and individually valued
Total Sum Insured
Personal Money/Credit Cards	No Yes
Pedal Cycles	No Yes
If YES to cover for pedal cycles, please advise replacement value of most expensive cycle
Buildings (covers the home and all outbuildings)
Type of Cover	Standard 'Reinstatement' Standard plus full Accidental Damage
Sum Insured (The cost of rebuilding your home - not market value)
Subsidence Problems	No Yes
Possible Security Discounts
Window locks & 5 lever mortice deadlocks fitted
Member of Approved Neighbourhood Watch scheme
NACOSS approved alarm system installed
Previous Claims
Have you claimed on your Household Insurance in the last five years	Please select Yes No
Detail all Household Claims made by you (if any) during the past five years. Please advise Incident Date / Amount Claimed / Circumstances
Civil Convictions (In past 10 years)
Amounts/Fines
Circumstances/Sentence
Additional Information
Start date for cover or existing renewal date	/ / (dd/mm/yyyy)
Existing Insurer
Present Premium (optional)
Where did you hear about us?	Please select... Google AltaVista UK Plus MSN Ask Find Other Search Engine Yellow Pages Recommendation Radio Advertisment Existing Client Other