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Insurance Application Form

Insurance Application Form

Insurance Application Form

The information in this form will be used to provide an insurance quotation and it is important that you answer all questions to the best of your knowledge. If you are unsure about any part then please call our team on 01792 315500 option 5.

If preferred a form can be emailed to you or it can be completed by telephone.

Property Details

1

Proposer Details

2

Section A

3

Section B

4

Your Cover

Do you know when the date cover is required from?

Do you know when the date cover is required from? *

Yes No, to be advised

Date cover is required from

Date Cover is required from

Property Details

Address to be insured

First Line of Address

Second Line of Address

City

Postcode

Type of building

Type of Building *

Type Of Building *

Number of Bedrooms

Number of Bedrooms *

Year of Build

Year of Build *

Exact year if known

Year of Build

Claims History

Have you suffered any loss, damage, injury or liability in the last five years? (whether insured or not) from any of the events to be insured by this policy?

Claims History *

Yes No

If yes, please provide full details including dates, circumstances and costs involved:

Claims History Extra

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Proposer One Details

Proposer Title

Full Name

Proposer Date of Birth

Proposer Email

Proposer Telephone

Proposer Mobile

Click here if the property address and the proposer 1 address is the same

Proposer Address 1

Proposer Address 2

Proposer City

Proposer Postcode 1

Proposer Two Details

Proposer Title

Full Name

Proposer Date of Birth

Proposer Email

Proposer Telephone

Proposer Mobile

Proposer Address 1

Proposer Address 2

Proposer City

Proposer Postcode 2

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Section A: Is the property to be insured…

Of standard construction i.e. constructed of brick, stone or concrete and roofed with slate, tiles, concrete, metal or asbestos?

Of standard construction i.e. constructed of brick, stone or concrete and roofed with slate, tiles, concrete, metal or asbestos? *

Yes No

Please Provide Additional Details

Additional Text

In good state of repair?

In good state of repair? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Used for business purposes or open to the public?

Used for business purposes or open to the public? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Owned outright or mortgaged by the proposers?

Owned outright or mortgaged by the proposers? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Occupied as your main permanent residence?

Occupied as your main permanent residence? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Let to others or occupied by paying guests (if yes please answer the questions in Section B)

Let to others or occupied by paying guests (if yes please answer the questions in Section B) *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Currently unoccupied

Currently unoccupied *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Left unattended for more than 60 consecutive days?

Left unattended for more than 60 consecutive days? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Undergoing (or you are planning) any structural work or alteration?

Undergoing (or you are planning) any structural work or alteration? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Free from any history of flooding?

Free from any history of flooding? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Free from subsidence, landslip or ground heave?

Free from subsidence, landslip or ground heave? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Free from any underpinning or history of monitoring for structural movement?

Free from any underpinning or history of monitoring for structural movement? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

A Listed Building?

A Listed Building? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Have you, or any member of your household permanently living with you…

Ever had a proposal for insurance declined, renewal refused, cover terminated, increased premium required or special conditions imposed by any insurer?

Ever had a proposal for insurance declined, renewal refused, cover terminated, increased premium required or special conditions imposed by any insurer?

Yes No

Please Provide Additional Details

Please Provide Additional Details

Ever been convicted of or cautioned for (or charged but not yet tried with) any criminal offence other than motoring offences that is not considered to be “spent” under the Rehabilitation of Offenders Act?

Ever been convicted of or cautioned for (or charged but not yet tried with) any criminal offence other than motoring offences that is not considered to be “spent” under the Rehabilitation of Offenders Act? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Ever been declared bankrupt or insolvent, been disqualified from being a company director or ever been the subject of bankruptcy proceedings, CCJ’s or IVA’s?

Ever been declared bankrupt or insolvent, been disqualified from being a company director or ever been the subject of bankruptcy proceedings, CCJ’s or IVA’s? *

Yes No

Please Provide Additional Details

Please Provide Additional Details

Back Continue

Section B: Tenanted Property

If you answered ‘No’ to “Let to others or occupied by paying guests”, you can skip this section and jump to “’Finish” at the bottom of this page.

Will this property be let out to tenants?

Will this property be let out to tenants?

Yes No

Please Provide Additional Details

Please Provide Additional Details

Is any part of the property used as bedsits, hostel, holiday lets, student, asylum seekers or by tenants placed directly by DWP (DSS) or Local Authority?

Is any part of the property used as bedsits, hostel, holiday lets, student, asylum seekers or by tenants placed directly by DWP (DSS) or Local Authority?

Yes No

Please Provide Additional Details

Please Provide Additional Details

Is the tenancy agreement under the sole control of a management company/letting agent where you have no control on selection of the tenancy type?

Is the tenancy agreement under the sole control of a management company/letting agent where you have no control on selection of the tenancy type?

Yes No

Please Provide Additional Details

Please Provide Additional Details

Is the property let as a House in Multiple Occupation (HMO)?

Is the property let as a House in Multiple Occupation (HMO)?

Yes No

Please Provide Additional Details

Please Provide Additional Details

Does the tenancy involve the placement of ex prison offenders?

Does the tenancy involve the placement of ex prison offenders?

Yes No

Please Provide Additional Details

Please Provide Additional Details

How many tenants occupy the property?

How many tenants occupy the property?

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