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Household Insurance
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.
Applicant's Details Partner's Details (if joint application):
Full Name: * Name:
Occupation: Occupation:
D.O.B: D.O.B:
Contact Details:  
Address Line 1: City:
Address Line 2: County:
Postcode: Tel No.: *
Email: Mobile No.:

Please give details of all other persons aged over 18 residing at the insured property (other than the applicant/s)
Number of minors (aged under 18) residing at the property
Name, Age, Occupation, Relationship

Declarations about you and your home
Please read the following statements carefully and tick only those which apply
The home is occupied by someone other than the applicant(s) and their relatives, or occupied in whole or part by tenants or paying guests.
The applicant(s) or someone living in the home has been convicted of, or received a police caution for any criminal offence (other than motoring offences) or has a prosecution pending.
The applicant(s) or someone liVing in the home has previously had an insurance policy cancelled, been refused insurance or had special terms Imposed.
The home (including any garages or outbuildings) is used for business purposes and/or there are callers to the property in connection with the applicant's business or profession.
The applicant(s) or someone living in the home is engaged in the entertainment business.
The applicant(s) or someone living in the home has been declared bankrupt.
The applicant(s) or someone living in the home smokes.
If property is owned is it: If property is rented is it:
Outright?    
On mortgage?
Furnished?
Part Furnished?
Unfurnished?
Roll / Account Number
Mortgage lender (name and address)
If the Insured address is different to the correspondence address, enter this below.
(If Insured address has been lived at for less than 12 months please note previous address in additional notes section)
Property description:
Detached house
Semi-detached house
Terraced house
Detached bungalow
Semi-detached bungalow
Number of bedrooms    

Terraced bungalow
Flat
Maisonette
Studio
Other
Year home was built    
Declarations about you and your home
Please read the following statements carefully and tick only those which apply
The home has a non standard construc1lon (i.e. the external walls are not built of brick. stone or concrete, or less than 80% of the home is not roofed with slate, clay or concrete tiles, concrete or metal).
The property is solely built of stone.
The property uses asbestos in its construction.
The home (including garage) is in a bad state of repair or is not maintained.
The home is not self contained (i.e. it does not have a separate and private entrance under your sole control).
The home will not be lived in from commencement date of this insurance or completion of purchase.
The home (including garage) is in a locality where there is evidence (or a history) of subsidence, heave, landslip or flooding
The home (including garage and outbuildings) has sustained previous damage by subsidence, heave or landslip, and/or has it been underpinned or provided with other means of struc1ural support.
The home is not my main residence, or is a holiday (or weekend) home, or is likely 10 be left unoccupied for more than 30 days at a time.
The home (including garage) is situated less than mile (400m) from the nearest river, watercourse or sea.
The home (including garage) is currently undergoing renovation or construction work.
The home is a listed building.
The home is normally unoccupied throughout the day.
The home is normally unoccupied outside normal working hours.
The home is not fitted with any smoke detectors.
The home does not have a gas central heating system.

Buildings Insurance		  
Buildings Sum Insured (£) Buildings Total Excess (£)
Type of cover Standard
Standard & Accidental Damage		 Claims Free Years
Date of Purchase Date of Occupancy
Contents Insurance      
Contents Sum Insured (£) Contents Total Excess (£)
Type of cover Standard
Standard & Accidental Damage		 Claims Free Years
     
Amount of valuables included within Contents Sum Insured (£)
Details (inc value) of valuables worth over £1000
 
 
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? Yes No
Is your home protected by an intruder alarm system installed and maintained by a NACOSS (National Approval Council for Security Systems) recognised firm? Yes No
Burglar alarm Installation Company Burglar alarm Maintenance Company
Are you a member of a police approved Neighbourhood Watch Scheme? Yes No
Are there any other protections installed at the insured property? Yes No
Enter details of additional protections at the property
Personal Possessions Cover
Unspecified Personal Possessions Sum Insured (£)
Details of Specified Personal Possessions
(Group, Description, Value)
Details of Pedal Cycles & Accessories
(Manufacture, Model, Value)
Insurance History
Have you held insurance before? Yes No
Previous insurer
Policy number
Details of previous claims and losses
(Date, Category, Amount, Details)
Optional Extras
Family Legal Protection
Garden Cover
Additional Notes
Licensed broker 340249 established 1973.
Authorised & regulated by the Financial Service Authority (FSA no. 301033) 		FSA - Financial Service Authority