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When completing the form below, or having your Insurance Advisor complete it on your behalf, you must provide all material facts. Failure to disclose such necessary information or disclose false information could invalidate any insurance cover in the event of a claim.
1. FIRST APPLICANT’S DETAILS
Title Forename(s)
Surname DOB
Occupation
Nature of Business
Current Employer Name
2. SECOND APPLICANT’S DETAILS
Title Forename(s)
Surname DOB
Occupation
Nature of Business
Current Employer Name
3. CONTACT DETAILS
Correspondence Address(s)
Applicant 1 Contact Tel
Applicant 2 Contact Tel
4. PROPERTY DETAILS
If the insured address is different to the correspondence address,
enter this below.
Property description Semi-detached bungalow
Detached house Terraced bungalow
Semi-detached house Flat
Terraced house Other
Detached bungalow  
Number of bedrooms Year property was built
Property Security
1. Is the final exit door secured by a deadlock, all other
external doors either secured by a deadlock or fitted top
and bottom with key operated security bolts, and accessible windows fitted with key operated window locks?
2. Is your home protected by an intruder alarm system
installed and maintained by a NACOSS (National Approval
Council for Security Systems) recognised firm?
Name of burglar alarm Installation Company
Name of burglar alarm Maintenance Company
Are you a member of a police approved Neighbourhood
Watch Scheme?
Are there any other protections installed at the insured
property?
Enter details of additional protections at the property
8. GENERAL PROPERTY INFORMATION
Declarations about you and your home
Please read the following statements carefully and
tick only those which apply
The buildings sum insured do not represent the full rebuilding costs for Building cover
The contents sum insured do not represent the full replacement cost of all items insured (less an allowance to wear and tear)
The property is not built of brick, stone or concrete, or not roofed with slates, tiles, metal, asphalt or concrete
The property is not in a good state of repair, or has damage or defects of some kind
The property is in an area susceptible to flooding
The property or area is subject to subsidence, ground heave, landslip or coastal or river erosion
The property is subject to previous underpinning or any remedial action of any type in connection with subsidence, ground heave, landslip or coastal or river erosion
The property contains a restaurant or other social amenities
The property is not occupied solely for private residential purposes
The property is normally unoccupied at night, or may be left unoccupied for more than 30 consecutive days
The property may be left unoccupied for more than 60 consecutive days
The property is a listed building
The private dwelling houses or flats are let as bedsitters, short-term lets or holiday accommodation for a tenancy agreement of less than 6 months
During the last 5 years you or your spouse (or in the case of a firm, any director or partner) have suffered loss, destruction or damage, or have been liable for accidents involving other persons with respect to the events which you wish to insure against
An insurer has imposed terms or previously declined (at any time) with respect to the risks to be insured
You or any members or you family or anyone normally residing with you (or, in the case of a firm, any director or partner) have been subject to any declaration of bankruptcy or liquidation
The applicant(s) or any person living in the home has been convicted of, or received a police caution for any criminal offence (other than motoring offences) or there is a prosecution(s) pending
The applicant has one or more convictions for fraud or dishonesty (of any kind)
The property is not currently occupied
The property is not self-contained (i.e. it does not have a separate private entrance under your sole control)
The property will not be occupied from commencement
The property (including garage) is showing signs of movement (e.g. cracking or bulging walls) which could be attributed to subsidence, heave, landslip or flooding
The property (including garage) is situated within ¼ mile (400m) of the nearest river, watercourse or sea
The property contains cooking or washing facilities (other than hand basins) in the bedroom(s)
The applicant(s) or someone living in the property is engaged in the entertainment profession
5. PROPERTY OWNERSHIP
Owned on Mortgage By Proposer – Let Furnished
Owned on Mortgage By Proposer – Let Unfurnished
Owned on Mortgage By Proposer – Not Let
Owned on Mortgage By Proposer – Sometimes Let Furnished
Owned on Mortgage By Proposer – Sometimes Let Unfurnished
Owned Outright By Proposer - Let Furnished
Owned Outright By Proposer - Let Unfurnished
Owned Outright By Proposer – Not Let
Owned Outright By Proposer – Sometimes Let Furnished
Owned Outright By Proposer – Sometimes Let Unfurnished
Rented From Local Authority – Furnished
Rented From Local Authority – Unfurnished
Tied Occupancy – Furnished
Tied Occupancy - Unfurnished
Not Covered By Any Other Item On The List
Date of Purchase
Date of Occupancy
Mortgage Lender Details (If App.)
6. BUILDINGS COVER
Buildings Sum Insured
Type of cover
Buildings Total Excess
Claim Free Years
7. CONTENTS COVER
(Covers landlord’s contents only)
Contents Sum Insured
Buildings Total Excess
Claims Free Years
General property information continued…
The property (including garage) is undergoing renovation or construction work
The property does not have a gas central heating system
The property is regularly left unattended ( excluding normal employment, holiday or shopping purposes)
The property will be occupied by someone other than a family, a married or common law couple, a single person, or a maximum of two unrelated persons sharing
The property will be occupied by students, the unemployed or DSS, Local Authority or charity referrals, or let to local authorities or housing associations
The applicant(s) or any other individual permanently residing at the property is a smoker
The property is usually unoccupied during work hours
The property has patio doors
The property is a holiday home
The property is undergoing Non-Standard Renovation
The property requires Joint Contract Terms cover
The property is pending sale
The property has flat felt on a timber roof, which exceeds 50% of the total roof area
You or an authorised representative (e.g. Caretaker) will not be permanently resident at the insured address
The premises are not protected with fire detection/prevention facilities, or has no smoke alarm, fire extinguisher and fire blanket
The property use asbestos in some part of its construction
The property forms part of a portfolio, where the majority of risks fall within the acceptable business criteria
9. TENANCY
Please complete this section if the property is tenanted
Type of Tenants
Working people Housing Association
Students Local Authority
DSS Family / Single Asylum Seekers
The property is multi-tenure
The tenant share kitchen facilities
References are not always taken
The tenancy agreement is not with the tenant
Length of tenancy agreement Year(s) Month(s)
Provide details of all persons residing at the property
10. INSURANCE DETAILS
What date do you want cover to commence?
(Cover can not be backdated)
Have you held insurance before?
Previous insurer:
Policy number:
 
Details of previous claims and losses:  
Date Type Cost Cause
Licensed broker 340249 established 1973.
Authorised & regulated by the Financial Service Authority (FSA no. 301033)
FSA - Financial Service Authority