If your insurance is coming up for renewal or you are looking to apply for insurance for the first time, please complete the following form and a mortgage adviser will be in contact to discuss your needs in more detail.

Prior to completing the following for submission for a quotation, please confirm the following:

The property to be insured (including garage and outbuildings):

• Is in good state of repair
• Is not undergoing renovation or construction work
• Is self contained and is the proposer’s permanent residence – not a holiday home, weekend/weekday home or mobile home
• Is not occupied by anyone other than family members e.g. tenants or paying guests
• Is not left unoccupied for any period exceeding 30 consecutive days
• Is roofed 80% or more with slates, clay or concrete tiles, concrete or metal
• Is not used for business other than for administrative or clerical purposes

To the best of your knowledge the property to be insured (including garage and outbuildings):

• Has never flooded
• Has not been underpinned
• Is not showing any signs of movement (e.g. cracking or bulging of walls) and has never suffered from subsidence, landslip or ground heave
• Is not in a locality where there is evidence or a history of subsidence, landslip, ground heave or flooding
• Is not a listed building

The occupants of the property:

• Have not had any insurance cancelled, declined, refused, or special terms imposed
• Are not engaged in the entertainment profession
• Have never been convicted of any criminal offence (other than motoring offence) or have any prosecution pending
  

I confirm that the above statements are true: Yes No Unsure Please select:

Incorrect disclosure could mean a policy claim is not met and a policy could be made null and void.

Who owns and occupies the property:	Owned and Occupied by you Mortgaged and Occupied by you Renting furnished by private landlord Renting unfurnished by private landlord Renting furnished by local authority Renting unfurnished by local authority Renting furnished by housing association Renting unfurnished by housing association Please select:
Level of Cover required:	Buildings Only Contents Only Buildings and Contents Please select:
First time buyer?:	Yes No Please select:
Is this a Joint Application?:	Yes No Please select:

 

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Section One - Personal Details

	Applicant 1	Applicant 2
Title	Please select: Mr Mrs Ms Miss Dr Professor Other	Please select: Mr Mrs Ms Miss Dr Professor Other
If other, please state
	name as shown on passport
First name
Middle names
Surname
Date of Birth	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 dd 01 02 03 04 05 06 07 08 09 10 11 12 mm 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 yyyy	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 dd 01 02 03 04 05 06 07 08 09 10 11 12 mm 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 yyyy
Sex	Please select: male female	Please select: male female
Home telephone number
Work telephone number
Mobile telephone number
Email address
Marital status	Please select: Single Married Married - Common Law Married - Civil Law Separated Widowed Partner Partner- Civil	Please select: Single Married Married - Common Law Married - Civil Law Separated Widowed Partner Partner- Civil
Occupation
Nature of business
Employment Status	Please select: Employed Retired Self employed Unemployed Unemployed due to disability House person Director or Partner Full or part-time education	Please select: Employed Retired Unemployed Unemployed due to disability House person Director or Partner Full or part-time education

 

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Section Two - Risk Address

1st Line Address
2nd Line Address
3rd Line Address
Town or City
County	Please select: Bedfordshire Berkshire Bristol Buckinghamshire Cambridgeshire Cheshire City of London Cornwall Cumbria Derbyshire Devon Dorset Durham East Riding of Yorkshire East Sussex Essex Gloucestershire Greater London Greater Manchester Hampshire Herefordshire Hertfordshire Isle of Wight Kent Lancashire Leicestershire Lincolnshire Merseyside Norfolk North Yorkshire Northamptonshire Northumberland Nottinghamshire Oxfordshire Rutland Shropshire Somerset South Yorkshire Staffordshire Suffolk Surrey Tyne and Wear Warwickshire West Midlands West Sussex West Yorkshire Wiltshire Worcestershire Anglesey Brecknockshire Caernarfonshire Carmarthenshire Cardiganshire Denbighshire Flintshire Glamorgan Merioneth Monmouthshire Montgomeryshire Pembrokeshire Radnorshire Aberdeenshire Angus Argyllshire Ayrshire Banffshire Berwickshire Buteshire Cromartyshire Caithness Clackmannanshire Dumfriesshire Dunbartonshire East Lothian Fife Inverness-shire Kincardineshire Kinross Kirkcudbrightshire Lanarkshire Midlothian Morayshire Nairnshire Orkney Peeblesshire Perthshire Renfrewshire Ross-shire Roxburghshire Selkirkshire Shetland Stirlingshire Sutherland West Lothian Wigtownshire Antrim Armagh Down Fermanagh Londonderry Tyrone Please select : Bedfordshire Berkshire Bristol Buckinghamshire Cambridgeshire Cheshire City of London Cornwall Cumbria Derbyshire Devon Dorset Durham East Riding of Yorkshire East Sussex Essex Gloucestershire Greater London Greater Manchester Hampshire Herefordshire Hertfordshire Isle of Wight Kent Lancashire Leicestershire Lincolnshire Merseyside Norfolk North Yorkshire Northamptonshire Northumberland Nottinghamshire Oxfordshire Rutland Shropshire Somerset South Yorkshire Staffordshire Suffolk Surrey Tyne and Wear Warwickshire West Midlands West Sussex West Yorkshire Wiltshire Worcestershire Anglesey Brecknockshire Caernarfonshire Carmarthenshire Cardiganshire Denbighshire Flintshire Glamorgan Merioneth Monmouthshire Montgomeryshire Pembrokeshire Radnorshire Aberdeenshire Angus Argyllshire Ayrshire Banffshire Berwickshire Buteshire Cromartyshire Caithness Clackmannanshire Dumfriesshire Dunbartonshire East Lothian Fife Inverness-shire Kincardineshire Kinross Kirkcudbrightshire Lanarkshire Midlothian Morayshire Nairnshire Orkney Peeblesshire Perthshire Renfrewshire Ross-shire Roxburghshire Selkirkshire Shetland Stirlingshire Sutherland West Lothian Wigtownshire Antrim Armagh Down Fermanagh Londonderry Tyrone Bedfordshire Berkshire Bristol Buckinghamshire Cambridgeshire Cheshire City of London Cornwall Cumbria Derbyshire Devon Dorset Durham East Riding of Yorkshire East Sussex Essex Gloucestershire Greater London Greater Manchester Hampshire Herefordshire Hertfordshire Isle of Wight Kent Lancashire Leicestershire Lincolnshire Merseyside Norfolk North Yorkshire Northamptonshire Northumberland Nottinghamshire Oxfordshire Rutland Shropshire Somerset South Yorkshire Staffordshire Suffolk Surrey Tyne and Wear Warwickshire West Midlands West Sussex West Yorkshire Wiltshire Worcestershire Anglesey Brecknockshire Caernarfonshire Carmarthenshire Cardiganshire Denbighshire Flintshire Glamorgan Merioneth Monmouthshire Montgomeryshire Pembrokeshire Radnorshire Aberdeenshire Angus Argyllshire Ayrshire Banffshire Berwickshire Buteshire Cromartyshire Caithness Clackmannanshire Dumfriesshire Dunbartonshire East Lothian Fife Inverness-shire Kincardineshire Kinross Kirkcudbrightshire Lanarkshire Midlothian Morayshire Nairnshire Orkney Peeblesshire Perthshire Renfrewshire Ross-shire Roxburghshire Selkirkshire Shetland Stirlingshire Sutherland West Lothian Wigtownshire Antrim Armagh Down Fermanagh Londonderry Tyrone
Post Code
Date property occupied	01 02 03 04 05 06 07 08 09 10 11 12 mm 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 yyyy
Correspondence Address (if different from Risk Address)
1st Line Address*
2nd Line Address*
3rd line Address*
Town or City*
County*	Please select: Bedfordshire Berkshire Bristol Buckinghamshire Cambridgeshire Cheshire City of London Cornwall Cumbria Derbyshire Devon Dorset Durham East Riding of Yorkshire East Sussex Essex Gloucestershire Greater London Greater Manchester Hampshire Herefordshire Hertfordshire Isle of Wight Kent Lancashire Leicestershire Lincolnshire Merseyside Norfolk North Yorkshire Northamptonshire Northumberland Nottinghamshire Oxfordshire Rutland Shropshire Somerset South Yorkshire Staffordshire Suffolk Surrey Tyne and Wear Warwickshire West Midlands West Sussex West Yorkshire Wiltshire Worcestershire Anglesey Brecknockshire Caernarfonshire Carmarthenshire Cardiganshire Denbighshire Flintshire Glamorgan Merioneth Monmouthshire Montgomeryshire Pembrokeshire Radnorshire Aberdeenshire Angus Argyllshire Ayrshire Banffshire Berwickshire Buteshire Cromartyshire Caithness Clackmannanshire Dumfriesshire Dunbartonshire East Lothian Fife Inverness-shire Kincardineshire Kinross Kirkcudbrightshire Lanarkshire Midlothian Morayshire Nairnshire Orkney Peeblesshire Perthshire Renfrewshire Ross-shire Roxburghshire Selkirkshire Shetland Stirlingshire Sutherland West Lothian Wigtownshire Antrim Armagh Down Fermanagh Londonderry Tyrone Please select : Bedfordshire Berkshire Bristol Buckinghamshire Cambridgeshire Cheshire City of London Cornwall Cumbria Derbyshire Devon Dorset Durham East Riding of Yorkshire East Sussex Essex Gloucestershire Greater London Greater Manchester Hampshire Herefordshire Hertfordshire Isle of Wight Kent Lancashire Leicestershire Lincolnshire Merseyside Norfolk North Yorkshire Northamptonshire Northumberland Nottinghamshire Oxfordshire Rutland Shropshire Somerset South Yorkshire Staffordshire Suffolk Surrey Tyne and Wear Warwickshire West Midlands West Sussex West Yorkshire Wiltshire Worcestershire Anglesey Brecknockshire Caernarfonshire Carmarthenshire Cardiganshire Denbighshire Flintshire Glamorgan Merioneth Monmouthshire Montgomeryshire Pembrokeshire Radnorshire Aberdeenshire Angus Argyllshire Ayrshire Banffshire Berwickshire Buteshire Cromartyshire Caithness Clackmannanshire Dumfriesshire Dunbartonshire East Lothian Fife Inverness-shire Kincardineshire Kinross Kirkcudbrightshire Lanarkshire Midlothian Morayshire Nairnshire Orkney Peeblesshire Perthshire Renfrewshire Ross-shire Roxburghshire Selkirkshire Shetland Stirlingshire Sutherland West Lothian Wigtownshire Antrim Armagh Down Fermanagh Londonderry Tyrone Bedfordshire Berkshire Bristol Buckinghamshire Cambridgeshire Cheshire City of London Cornwall Cumbria Derbyshire Devon Dorset Durham East Riding of Yorkshire East Sussex Essex Gloucestershire Greater London Greater Manchester Hampshire Herefordshire Hertfordshire Isle of Wight Kent Lancashire Leicestershire Lincolnshire Merseyside Norfolk North Yorkshire Northamptonshire Northumberland Nottinghamshire Oxfordshire Rutland Shropshire Somerset South Yorkshire Staffordshire Suffolk Surrey Tyne and Wear Warwickshire West Midlands West Sussex West Yorkshire Wiltshire Worcestershire Anglesey Brecknockshire Caernarfonshire Carmarthenshire Cardiganshire Denbighshire Flintshire Glamorgan Merioneth Monmouthshire Montgomeryshire Pembrokeshire Radnorshire Aberdeenshire Angus Argyllshire Ayrshire Banffshire Berwickshire Buteshire Cromartyshire Caithness Clackmannanshire Dumfriesshire Dunbartonshire East Lothian Fife Inverness-shire Kincardineshire Kinross Kirkcudbrightshire Lanarkshire Midlothian Morayshire Nairnshire Orkney Peeblesshire Perthshire Renfrewshire Ross-shire Roxburghshire Selkirkshire Shetland Stirlingshire Sutherland West Lothian Wigtownshire Antrim Armagh Down Fermanagh Londonderry Tyrone
Post code*

 

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Section Three - Property Description

Wall construction:	Please select: Brick Concrete Flint Stone Timber Brick and Timber Frame Cob Construction Metal Prefab (Non-Combustable) Stramit Unknown
Roof construction:	Please select: Tile Slate Felt on timber Concrete Metal Timber Asphalt Shingle Stramit Thatch - fibre Thatch - reed Turnerised Woodwork Unknown
Property type:	Please select: House – Detached House – Semi detached House – Linked detached House – Mid terrace House – End Terrace Townhouse – Mid terrace Townhouse – End terrace Bungalow – Detached Bungalow – Semi detached Bungalow – Mid terrace Bungalow – End terrace Chalet Purpose built flat Converted flat Serviced flat within business premises Maisonette – Detached Maisonette –Semi detached Maisonette – Mid terrace Maisonette – End terrace Unknown
Floor number of flat (if applicable):	Please select: Basement Ground First Second Third Fourth Fifith Sixth Seventh Eighth
Number of floors in block (if applicable)	Please select: 2 3 4 5 6 7 8
Approx. year of construction:
Number of bedrooms	Please select: 1 2 3 4 5 6 7 8 9 10+
Does the property have a smoke detector?	Please select: Yes No
Will the property be left unoccupied during normal working hours?	Please select: Yes No
Will the property be left unoccupied during the night?	Please select: Yes No
Are any of the occupants smokers?	Please select: Yes No
Total number of residents?	Please select: 1 2 3 4 5 6 7 8 9 10+
Number of residents under 18?	Please select: o 1 2 3 4 5 6

 

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Section Four - Property Security

Windows:	Please select: Key operated window locks Not listed or no specific security
Final exit doors:	Please select: 3 bolt Multipoint locking system Mortice deadlock – 5 or more levers Mortice deadlock – 5 or more levers BS362 Rim lock automatic deadlock Not listed or no specific security
Alarm:	Please select: None Audible Only BT ABC BT Redcare Central Station direct line NACOSS or SSAIB Packnet
Member of neighbourhood watch?	Please select: Yes No

 

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Section Five - Part 1- Buildings Insurance

How many years Insurance held?	Please select: 0 1 2 3 4 5+
Accidental Damage required?	Please select: Yes No
Sum assured:
Voluntary excess:	Please select: £50 £100 £150 £200 £250 £300 £350 £400 £450 £500 £550 £600 £650 £700 £750 £800 £850 £900 £950 £1000

 

Section Five - Part 2 - Contents Insurance

How many years Insurance held?	Please select: 0 1 2 3 4 5+
Accidental Damage required?	Please select: Yes No
Sum assured:
Voluntary excess:	Please select: £50 £100 £150 £200 £250 £300 £350 £400 £450 £500 £550 £600 £650 £700 £750 £800 £850 £900 £950 £1000
Unspecified personal possessions – cover for items away from the home (leave blank if not required) :
Cover for money (leave blank if not required):
Cover for credit cards (leave blank if not required):
Family Legal Protection required?	Please select: Yes No

 

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Section Six - Specified items (cover for specific valuable items within the home over £1,500)

Angling equipment		Please select: Yes No
Antique furniture		Please select: Yes No
Antique/Rare books		Please select: Yes No
Archery equipment		Please select: Yes No
Articles made of precious stones		Please select: Yes No
Camcorders		Please select: Yes No
Camping equipment		Please select: Yes No
China		Please select: Yes No
China, glass and porcelain		Please select: Yes No
Clocks		Please select: Yes No
Clothing		Please select: Yes No
Coin collection		Please select: Yes No
Computer equipment		Please select: Yes No
Cups, shields, trophies and Masonic regalia		Please select: Yes No
Curios		Please select: Yes No
Furniture		Please select: Yes No
Furs		Please select: Yes No
Gold items		Please select: Yes No
Golfing equipment		Please select: Yes No
Guns		Please select: Yes No
Hearing Aids		Please select: Yes No
Jewellery/Watches		Please select: Yes No
Medal collection		Please select: Yes No
Mobile phones		Please select: Yes No
Musical Instruments – Amateur		Please select: Yes No
Musical Instruments – Professional		Please select: Yes No
Paintings		Please select: Yes No
Personal effects		Please select: Yes No
Personal effects (worldwide)		Please select: Yes No
Personal items excluding jewellery		Please select: Yes No
Personal Money		Please select: Yes No
Photographic equipment – Amateur		Please select: Yes No
Photographic equipment – Professional		Please select: Yes No
Pianos		Please select: Yes No
Porcelain		Please select: Yes No
Portable computers		Please select: Yes No
Portable TV		Please select: Yes No
Prams and pushchairs		Please select: Yes No
Riding tack		Please select: Yes No
Rugs		Please select: Yes No
Sailboards		Please select: Yes No
Silver items		Please select: Yes No
Skis (including water skiis)		Please select: Yes No
Spectacles		Please select: Yes No
Sporting equipment		Please select: Yes No
Stamp collection		Please select: Yes No
Trailers		Please select: Yes No
TVs/Videos/HiFi/Radios		Please select: Yes No
Works of Art etc		Please select: Yes No

 

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Section Seven- Claims History

Have you or your family sustained any loss or damage or had any claims made against you for cover requested during the last 5 years whether insured or not?	Yes No Please select:
Date of claim(s) - Cover type e.g. Buildings or Contents - Amount type of claim e.g. fire etc., give details

 

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Section Eight - Any additional information to process your application or further information as requested in this form?

When would you like us to contact you? (Opening hours Monday – Friday 9am – 6pm, Saturday 10am – 2pm)

9am-10am 10am-11am 11am-12pm 12pm-1pm 1pm-2pm 2pm-3pm 3pm-4pm 4pm-5pm 5pm-6pm

By clicking on send I/we expressly consent to be being contacted without prior notice or arrangement by using the contact details I/we have provided on the form and further consent that such contact may be in relation to (a) my/our mortgage arrangements and/or (b) other products and services.

YOUR HOME MAY BE REPOSSESSED IF YOU DO NOT KEEP UP YOUR REPAYMENTS ON YOUR MORTGAGE