You, Proposer

• Name of proposer*

  Full Address of the property to be insured*

  Phone Number*

  Proposer date of birth*

  Email Address*

  Main Proposer Employment Status* Please select Employed Self-Employed Retired None - Household duites

  Employment description*

  Trade*

  Do you wish to add a joint proposer?*

  Yes

  No

  Name of Joint Proposer *

  Joint Proposer date of birth*

  Joint Proposer Occupation*

  Joint Proposer Employment Status* Employed Self-Employed Retired None - Household duites

  Joint Proposer Trade*

  Is the correspondence address different from the address to be insured?*

  Yes

  No

  Full Correspondence Address *

  Date cover is required*

Proposer History

Have you or any other proposer(s) or permanent members of the home to which this insurance may apply

• Any unspent/unsatisfied bankruptcies?*

  Yes

  No

  Any Individual Voluntary Arrangements (IVAs)?*

  Yes

  No

  Any County Court Judgements (CCJs)?*

  Yes

  No

  Ever had a household insurer decline to accept, cancel, or refuse to continue?*

  Yes

  No

  Have you been convicted of any criminal offence other than motoring offences?*

  Yes

  No

Premises Type

• Type of property* Please select Building Under Construction Chalet Detached Bungalow Detached House Detached House (Barn Conversion) Detached Maisonette Detached Town House End Terraced House End Town House Flats (Conversion To Existing Dwelling) Maisonette Conversion Maisonette Purpose Built Mansion Not Covered By Any Other Item On The List Purpose Built Flat/Apartment Residential Caravan Rooms Semi Detached Maisonette Semi-Detached Bungalow Semi-Detached House Semi-Detached House (Barn Conversion) Show House Unspecified Private Dwelling

  Is the property self-contained with no shared facilities and its own lockable entrance?*

  Yes

  No

  Year the property was built*

  Number of bedrooms*

Premises Occupancy

• Residence type* Please select Holiday Home Let Other Part Let Permanant Home Shared Occupancy Tied Occuapancy Unoccupied Weekday Home Weekend Home

  Type of use* Please select Owner Occupied Rented from Landlords by long term sick/unemployed Rented from Landlords by Professionals Rented from Landlords by Students Other

  Enter the other type of property use*

  Is the property occupied only by the proposer(s) and the proposers’ family?*

  Yes

  No

  What is the maximum number of consecutive days the property is to be unoccupied in any one year?*

  Will any part of the property be used for any business, trade, or profession other than clerical work?*

  Yes

  No

Property Description

• Is the main property to be insured constructed exclusively of brick, stone or concrete and roofed exclusively with slates, tiles, metal or concrete?*

  Yes

  No

  Is the property, including its outbuildings and walls, in a good state of repair and will maintained?*

  Yes

  No

  Is the property registered with an architectural interest?*

  Yes

  No

  Are there any building works in progress or planned within 12 months of inception?*

  Yes

  No

Roof Construction

• Percentage of the property's roof that is flat:*

  Please select Up to 33% 34% to 50% 51% to 75% 75% to 100% No flat roofs

Security

• Type of lock fitted to all final exit doors?*

  Please select 3 lever mortice deadlock Five lever mortice deadlock Multi Point locking System Rimlock Deadlock Standard Yale Other

  Enter details of the final exit door locks*

  Type of lock fitted to patio/French doors?*

  Please select Central Rail Key Only Central, Top & Bottom Key Multi Point locking system No Patio Door Other

  Enter details of the patio/French door locks*

  Are all accessible windows, fanlights and skylights fitted with key operated locks?*

  Yes

  No

  What type of intruder alarm is at your property?*

  Please select 24 Hour Central station BSI/NSI/SSAIB Maintained bells only BT Redcare Central station DIY Audible bells only GSM/Dial ip No alarm system Other

  Enter details of the intruder alarm system*

  What type of safe is installed at your property?*

  Please select Floor Anchored Freestanding No Safe Under Floor Wall

Subsidence, Landslip, Heave and Flood

• Are there any trees or shrubs within 7m of the home, whether inside or outside of the boundary of your property, which are more than 3m tall?*

  Yes

  No

  Enter details of the tres/shrubs in question*

  Are there any signs of internal or external stepped or diagonal cracking or bulging?*

  Yes

  No

  To the best of your knowledge, has the property within the last 25 years been, or is currently being, monitored for subsidence, landslip and heave?*

  Yes

  No

  Are you aware of any survey carried out on the property which mentions subsidence, landslip and heave in the last 25 years?*

  Yes

  No

  Are you aware of any buildings within 250 metres which have been subject to subsidence, landslip and heave in the last 25 years?*

  Yes

  No

  To the best of your knowledge, has the property suffered from subsidence, landslip and heave or been underpinned or cosmetically repaired in the last 25 years?*

  Yes

  No

  To the best of your knowledge has the property flooded in the past 25 years?*

  Yes

  No

Claims and Losses

• Have any of the proposer(s) or occupant(s) to which this insurance may apply suffered a loss or claim, which would be covered by this type of insurance, within the last 5 years? (whether a claim was made or not)*

  Yes

  No

• Date

  Type of Claim

  Claim Amount (£) £
• Date

  Type of Claim

  Claim Amount (£) £
• Date

  Type of Claim

  Claim Amount (£) £
• Date

  Type of Claim

  Claim Amount (£) £
• Date

  Type of Claim

  Claim Amount (£) £
• Date

  Type of Claim

  Claim Amount (£) £

Cover Required

• Contents Only

  Buildings Only

  Buildings and Contents

  Have any of the proposer(s) or occupant(s) to which this insurance may apply suffered a loss or claim, which would be covered by this type of insurance, within the last 5 years? (whether a claim was made or not)*

• Total value of Valuables held in the bank only?*

  £

  Pedal cycles are automatically covered within the home only up to an individual value of £500 per cycle. Do you have any Pedal Cycles you want to cover within the home ONLY with an individual value above £500?*

  Yes

  No

  Extended Domestic Deep Freeze cover?*

  Yes

  No

  Money and Credit Cards away from the home?*

  Yes

  No

Additional Details

• Any additional information about you or the property - Condition, Building Works, etc.