Home Insurance Quotation Form

Where did you hear about us?

If it was through word of mouth, please state the name of the referrer

This information is solely for our marketing purpose.

or No Recommendation

PERSONAL DETAILS

Title *

First Name *

Surname *

Date of birth *

Marital Status *

Employment Status *

If Employed/Self Employed, what is your occupation:

If Employed/Self Employed, what type of business:

Were you born in the UK

Yes
No

If No, when did you last become a UK resident?

Home owner *

Email

Contact Number *

Address *

Type of property *

Estimated year property built

Number of living rooms

Number of kitchens

Number of bathrooms

Number of bedrooms

Are there any trees taller than 10m within 5m of the property

Yes
No

Approximate % of flat roof

Do you own this property *

Who lives in the property *

How many years have they lived at the property

How many adults live in the property

How many children under the age of 18 live in the property

When is the property usually occupied

For how many days in a row is the property left empty (e.g. holidays)

Does anybody in the property smoke

Yes
No

Is the property ever used for business use *

Yes
No

Does the property have an alarm

What lock is fitted to your main door

What other lock is fitted to any other external doors

Do all ground floor windows have key operated locks

Yes
No

How many working smoke alarms are there in the property

Would you like accidental damage cover for buildings

Yes
No

How many years NCB do you have buildings insurance

Contents value of the property: (including fixtures, furniture, utensils)

Any specific items worth over £1000

Yes
No

Would you like cover away from home

Yes
No

Would you like accidental damage cover for contents

Yes
No

How many years NCB do you have content insurance

In the past 5 years, have you or anyone living at the property made any home insurance claims or suffered any losses or damage, whether insured or not

Yes
No

When would you like the cover to start

Assumptions bellow are correct: (input tick boxes what would be pre-ticked)

The Property

Is built with brick walls?

Is more than 400 meters away from water

Has a roof made of slate or tile

Is not a listed property

Has never shown signs of heave, landslip or subsidence

Is your main residence

Has not had underpinning or structural support

First Choice

Is not currently undergoing building work

First Choice

Has never suffered from flooding

First Choice

Has no significant cracks on the external walls

First Choice

Do you agree with the above assumptions?

Yes
No

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