Email:
Client Details: / Security Details:
Name: / Is the property in a neighbourhood watch area?Please select NoYes
Date of birth: / Is there a NSI/SSAIB alarm? Please select NoYes If yes:
Is the alarm covered by an annual maintenance agreement?Please select NoYes
Occupation:
(if joint) Name:
Date of birth: / Is there a safe?Please select NoYes If Yes, please give details:
Occupation: / Is the property fitted with 5 lever mortice deadlocks on all exit doors and key operated window locks?
Please select NoYes if no, please give details:
Address of property you are insuring:
Sums insured:
Buildings: The sum insured must represent the full rebuilding cost of your home (including the cost of professional fees and site clearance) and any garages, greenhouses and other outbuildings, swimming pools, walls, gates and fences.Contents:How much would it cost to replace the entire contents (including valuables and high risk items) of your property as new? Contents are household goods including furniture, furnishings (such as curtains and carpets) and all the items not fixed to the property. If you do not insure for the full amount, you may find that in the event of any loss, your claim will not be settled in full.
Buildings:(does not include damage caused by accident)
Main building: £
Post code: / Outbuildings and annexes: £
Property Details: / Total building sum insured: £
Occupancy:Please select Main residenceHoliday/second propertyHoliday LetProfessional letPart letUnoccupiedOther (please provide details / Is accidental damage cover required(only available on main residence)?Please select NoYes
Type of property:Please select House semi-detachedHouse end terraceHouse mid terraceFlatPark home (or the like)Other (please provide details)Bungalow detachedHouse detachedBungalow semi-detachedBungalow end terraceBungalow mid terraceBarn conversion 9or the like)
Construction:Please select BrickCobStoneTimberWattle & daubTimber frameOther (please provide details) / Contents:(does not include damage caused by accident)
Roof construction:Please select Corrugated sheetFlat (Asphalt) Thatch (water reed)Thatch (long straw)Thatch (Wheat straw)Thatch 9type unknown)TileSlateOther (please provide details) / General contents: £
If Thatch %: If Flat %: / Outdoor items: £
Grade if listed:Please select Grade 1Grade 2Unknown / Year built: / Gold, silver and plate: £
Heating:Please select Central heating (gas or oil)Multifuel stoveOpen fireWoodburning stoveOther (please provide details) / Redundant jewellery, watches, & other valuables never worn or taken out of the property: £
Are all chimneys/flues lined?Please select NoYes
Does the roof have a 60 minute fire barrier?Please select NoYes
Are there smoke detectors on each floor?Please select NoYes / Stamp & coin collections: £
Is there a smoke detector in the roof void?Please select NoYes / Fine art & antiques: £
Is there an up to date electrical installation certificate?
Please select NoYes / Total contents sum insured: £
The following are only available on main residence:
Has the property any history of subsidence, heave, landslip, flooding, or major fire?Please select NoYes
If yes, please provide details: / Is accidental damage cover required?Please select NoYes
Unspecified personal possessions (items you take out of your home) (single article limit £2,500): £
Specified personal possessions over £2.500 (items you take out of your home)
£
£
£
Does anyone work from home?Please select NoYes
Please state nature of work:
If yes, which level of cover is required?Please select ExtendedStandard
Pedal cycles (up to £500 total): £
Policy Excess:
There is a compulsory excess of £100 on main residence and £250 on all others.
Voluntary excess in addition:
Building:Please select £100£250£500£1,000
Contents:Please select £100£250£500£1,000 / Specified cycles (over £500)
£
Other information:
Are you planning any building works?Please select NoYes
If yes, please provide details:
Any claims in the last 5 years?Please select NoYes
If yes, please provide details: / If you Cannot confirm that:- Insurance has never been declined, you have never been declared bankrupt, you have no convictions (except motoring), please provide details:
Current insurer?
Renewal date? / Target premium: £
TEL: 01865 844980 Fax: 01865 841147 Email:
County Insurance Services limited (08411634) is Authorised and regulated by the Financial Conduct Authority (FRN: 597267)