Renewal date / Cover date?

Renewal premium?

Where did you hear about us?

Title?

First name?

Surname?

Date of Birth?

Occupation?

Title? (only complete to add a joint policyholder)

First name?

Surname?

Date of Birth?

Occupation?

Telephone number?

Email address?

House name / number?

Postcode?

Approxinmate year property built?

Approximate year property purchased?

Is the property?

Type of property?

Construction of the external walls?

Approximate percentage of any flat roof?

Number of bedrooms?

Is the property a listed building?

Rebuilding cost of the property?

Accidental damage cover required for buildings?

Buildings voluntary excess (with a premium discount)?

Contents sum insured?

Contents voluntary excess (with a premium discount)?

Any unspent criminal conviction(s) or prosecution(s) pending?

Ever been declared bankrupt or the subject of bankruptcy proceedings?

Ever had a proposal declined, had a policy cancelled by an insurer, renewal refused or had any special terms imposed?

Is the property located within 200 metres of a watercourse or previously been flooded?

Has the property ever been damaged by subsidence, ground heave or landslip, monitored for subsidence, survey reported settlement or movement, showing visible signs of cracking or within an area subject to subsidence or mining (past or present)?

Are there any trees or shrubs over 3 metres tall within 7 metres of the property?

Made any claims under home insurance policy for this or any other property or any incidents of damage or loss not insured, in the last 5 years?

If you have answered Yes to any of the questions above, please give details here.
For each claim in the last 5 years we need to know: [Month/Year], [Type of Claim] and [Cost].