Buildings and Contents Combined Insurance Quotation Form

Section 1 - Personal Details
Title	Mr Mrs Miss Ms Other	If Other Please Specify
First Name
Last Name
Full Address
Post Code
Date of Birth
Occupation
Business Description
Employment Status	Employed Self-Employed Retired Unemployed
Contact Number
Email Address
Best Time To Call
Is the Policy to be in joint names	Yes No
Name
Date of Birth
Relationship to Proposer
Occupation
Business Description
Employment Status	Employed Self-Employed Retired Unemployed
Does anyone in the property smoke	Yes No
Section 2 - Property Details
What year was the property constructed
Is the property a listed building	Yes No
What grade listing is the building
Type of property	Detached Link Detached Semi Detached Mid Terraced End Terraced Bungalow Other
Please specify
How many years have you lived at the property
Does the property have a flat roof	Yes No
Please provide percentage
Is the property Standard Construction	Yes No
What is the roof material
What is the Wall Construction
Number of bedrooms	1 2 3 4 5 6
Total buildings sum insured £	* please see below
Is Accidental Damage Cover Required	Yes No
How many people reside in the property
How many under the age of 18
Is the property free of subsidence / flooding / underpinning	Yes No
Please provide details
Is there an alarm fitted to the property	Yes No
Is it a Nacoss approved alarm and does it have a maintenance contract in force	Yes No
What type of Alarm is it	Audible Only BT Redcare BT ABC Central Station Direct Line Nacoss Approved Packnet
Has the property got either locks that conform to BS3621 or good quality 5 lever mortis deadlocks fitted to all external doors and key operated locks on all windows and pation doors	Yes No
Does the property have any exterior lighting	Yes No
Are there any smoke detectors in the home	Yes No
Total contents Sum Insured £
How much of the contents sum insured is represented by valuables
What is the value of the single most expensive item
Is Accidental Damage Cover Required	Yes No
Do you require cover for items away from the home	Yes No
Please give details of specific items including a complete description along with a valuation
Have you made any previous house hold claims in the last 5 years	Yes No
Previous Claim Claim Date Type of Claim Total Paid Out £ 1 2 3 4 5 6 7
Is there any business use that takes place at the property	Yes No
Please give details
How many years claim free do you have	0 1 2 3 4 5 6 7 8 9+
Inception / Renewal Date
Best Quote so Far £
Who is your present insurer
* The building sum insured should reflect the rebuild value of the property and not the market value. For further assistance please refer to www.abi.org.uk.