Home insurance – get a fast insurance quotation

Please complete the details below as fully as possible.

Proposer details

Title:

First names:

Last name:

Email address:

Daytime tel no:

Postal address:

Postcode:

Date of birth: D: M: Y:

Age:

Your occupation (include any part-time work):

Nature of employers business (or own if self-employed):

Your Partner / Joint Proposer

Title:

First names:

Last name:

Date of birth: D: M: Y:

Age:

Their occupation (include any part-time work):

Nature of employers business (or own if self-employed):

Your history

Construction of property:  Brick Stone Concrete Other

If other please give details:

Type of property:  Detached house Semi-detached house Terraced house Other Bungalow detached Bungalow semi-detached Bungalow terraced Other

If other please give details:

Number of bedrooms:

Cover Required:  Buildings Contents Terraced house Buildings & Contents

Buildings sum insured:

Contents sum insured:

If the property to be insured differs from your postal address above, please state the address and reason for the difference

Address of house to be insured:

Postcode:

Reason for difference:

Do you have a claims history (within 5 years)?  Yes No

If you ticked yes, you must fill in the section below:

Date: D: M: Y:

Details of loss:

Amount: