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Would you like to receive promotional material, offers and information about our new products?
Yes
No
Name
Address
Postcode
Contact telephone number
Marital status
Married
Single
Other
Date of Birth
Occupation
Do you have any disabilities?
Yes
No
Number of Adults over 18 years of age lives in the property?
1
2
3
4
5 or more
Number of Children
1
2
3
4
4+
Is this property your permanent home?
Yes
No
How long have you been resident at the property?
Less than a year
1 Year
2Years
3 Years
4 Years
5 Years
5+ Years
Number of Bedrooms
1
2
3
4
5
6
7
8
9
9+
Number of Bathrooms
1
2
3
4
4+
Is the construction Brick and Tiled roof?
Yes
No
Type of property?
Detached
Semi Detached
Bungalow
Town House
Flat
Other
Year Built
Is the property?
Owned
Rented
Has the property been extended?
Yes
No
Is the property unoccupied for a period longer than 30 days?
Yes
No
Is the property within 400m of a watercourse, river or sea?
Yes
No
Does the property have the following?
Alarm
5 Lever Locks on Doors
Window locks
Smoke Detectors
Neighbourhood Watch
None of the above
Type of cover required
Buildings Only
Contents Only
Buildings and Contents
Building sum insured
Do you want accidental damage?
Yes
No
Contents Sum insured
Do you want accidental damage?
Yes
No
Current Insurer
Renewal date
Years of NCD on buildings
0
1
2
3
4
5+
Years of NCD on contents
0
1
2
3
4
5+
Best quote so far
Do you wish to include unspecified all risk cover?
Yes
No
Sums insured amount
Please specify any items of value over £1,500 that which need to be covered outside the property.
Please outline the previous claims you have made.
Send
×
Motor Claims Notification Line
Call : 0343 5065 806
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