HOUSEHOLD QUOTE FORM

Your Email:

Name of proposer:

Date of birth:

Marital status:

1st Time Buyer:

Occupation:

Telephone Number:

Risk address:

Property type i.e. detached:

Is the property self contained?

Yes No

Is the property listed or preserved:

Yes No

Please provide any details of any mortgagee:

Year of build:

Is there an area of flat roof?

Yes No

Are any residents smokers?

Yes No

Total number of occupants:

Number of occupants under 18yrs old:

Standard Construction
Walls are built of brick, stone, slate or concrete and the roof is tiled, slate or concrete.

Yes No

Do you require Buildings cover:

Yes No

Do you require the wider accidental Damage cover?

Yes No

Buildings Sum Insured:

Do you require Contents cover:

Yes No

Do you require the wider Accidental Damage cover?

Yes No

Contents Sum Insured:

Do you require cover for items taken away from the home?

Yes No

If so please state the total value:

Intruder Alarm:

Do you have a smoke/fire Alarm:

Yes No

Are you a member of a Police approved neighbourhood watch scheme?

Yes No

Is your home occupied during the day?

Yes No

Can you comply with the following Material Facts statement?

Not been declared bankrupt/insolvent:

Yes No

Not been the subject of bankruptcy proceedings:

Yes No

Not had a proposal refused or declined:

Yes No

Not had a renewal refused:

Yes No

Not had insurance cancelled:

Yes No

Not had special terms imposed:

Yes No

Has no non-motoring convictions or criminal offences:

Yes No

Has no non-motor prosecutions pending:

Yes No

Minimum Security

Yes No

The Final Exit door of the premises to be fitted with a mortice deadlock which has 5 or more levers and or conforms to British Standard.

All other external doors and all internal doors giving access to any part of the buildings not occupied by the Policyholder for the purpose of the business be fitted with either:

A mortice deadlock with matching boxed striking plate

Or

Two key – operated security bolts for doors

All ground floor and basement opening windows/sky lights and other opening windows/skylights accessible from roofs, decks, balconies, fire escapes, canopies or down pipes be fitted with key-operated window locks.

Any previous claims in the Last 5 years?

Yes No

If yes, please provide details Including circumstance, date & amount :

Do you comply with the attached declaration?

Yes No

The property occupied solely by the proposer & members of the family as a permanent home

The property is not used for Business

The property is in a good state of repair and Proposer undertakes to maintain the property in a good state of repair

The property is of standard construction (walls built only of brick, stone or concrete or roofed with slates, tiles or concrete)

Motise Deadlock – 5 or more Levers BS3621 on all final exit or external doors

Key operated window locks on all opening windows and skylights

The property and surrounding area are free from flooding

The property and surrounding area are free from subsidence, ground heave & landslip

Property is not located within 400m of a river or cliff

Property has not been previously underpinned

Property is not undergoing any renovation or construction work

Renewal Date:

Current Insurer:

Target Premium: