REQUEST FOR QUOTATION
1.
Date of Request:
2.
Name:
Date of Birth
Occupation:
Name of Partner
(if applicable)
Date of Birth
Partners Occupation:
All other persons resident at the risk address. (including children)
Name:
Age:
Occupation:
Relationship
(to Proposed)
Name:
Age:
Occupation:
Relationship
(to Proposed)
Name:
Age:
Occupation:
Relationship
(to Proposed)
Name:
Age:
Occupation:
Relationship
(to Proposed)
Name:
Age:
Occupation:
Relationship
(to Proposed)
Email Address:
Please confirm Email :
4.
Risk Address:
Town:
County:
Postcode:
Telephone:
Correspondence Address if different to above
same as above
5
. Correspondence Address:
Town:
County:
Postcode:
6:
Your Occupation:
7
. Lenders Details:
8.
Including A/c Roll No:
Are the Mortgagee details to be noted:
Yes
No
9.
Date of Construction:
10.
Is the Property Listed:
Yes
No
11.
Type of Construction:
Standard
Non-Standard
ie. Brick, Stone, Pitched Roof - Standard
Timber Framed, Flat Roof - Non Standard
Number of Bedrooms:
12.
Type of Property
Flat
Terrace
Semi
Detatched
13.
Is your Home:
Rented
Owned
Other?
14.
Security Approved Locks:
Yes
No
Alarm:
Yes
No
Maintained Yearly:
Yes
No
Central Station:
Yes
No
15.
Intended Occupancy:
Unoccupied
Owner Occupied
Let
If Unoccupied or Let Give Full Details:
16.
Previous Insurer:
17.
Have you been refused insurance or had any terms/or restrictions imposed
at this or any previous home by any insurer:
Yes
No
If No terms are the current insurers aware of the conviction:
Yes
No
18.
Claims History last 6 Years:
Date
Settled Amount
Details
1.
2.
3.
If more than 3 Please give Details
:
19
. Has the Property suffered subsidence or movement of any type?
No
Yes
(If yes a survey may be required)
20.
Has the property suffered a flood claim?
No
Yes
(If yes a survey may be required)
If you are unsure about the following questions please leave blank and we will contact you at a later date for the information
21
.
Is the property within 400m of a watercourse?
Unsure
No
Yes
Type of Watercourse:
Distance away from Property:
How High Above highest Watermark:
What is between the Property & Watercourse
:
22.
Are there any trees within the 7 metres of the Property:
No
Yes
Type of Tree:
Distance from Property:
Height:
23.
Have you or any other people residing at the insured property ever been
convicted of a criminal offence other than a motoring offences?
No
Yes
Criminal Convictions
(if more than 3 please provide full details)
Name of person (s) with conviction
D.O.B.
Occupation
1.
2.
3.
Date (Month & Year)
Sentence and/or Fine
Served
1.
2.
3.
Details surrounding each conviction
(Please give full explanation for each conviction)
1.
2.
3.
24.
Have you ever been declared Bankrupt?
(if yes please give full details)
Yes
No
Details
Building Sum Insured: (min 35,000):
£
Contents Sum Insured (min £15,000)
£
All Risks (min 2,000)
£
Pedal Cycles
£
Money/Credit Cards
£
Other
£
25
. Other relevant information:
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Broker Details
Broker Name:
Contact Name:
Broker Address:
Town:
County:
Post:
Broker Tel:
Fax
:
Bureau Insurance Services Ltd. Tel: 01424 220110 Fax: 01424 217107
