| Personal Details |
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| Contact name: | | |
| Date of birth (dd/mm/yyyy): | | |
| Contact no: | | |
| Email: | | |
| NPA member no: | | |
| Address to be insured: | | |
| Is this your main address of residence?: | | |
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| General Information |
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| Number of adults in the household: | | |
| Number of children in the household: | | |
| Is the home occupied by you/your family? | | |
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| About your home |
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| Year built: | | |
| Number of bedrooms: | | |
| Wall construction: | | |
| Roof construction: | | |
| Building type: | | |
| Is the property free from flood damage? | | |
| Is the property free from Subsidence and there are no underpinnings in place? | | |
| Is the property in a good state of repair? | | |
| Alarm: | | |
| If yes, Alarm type: | | |
| Required Buildings Sum Insured | | |
| Have you made sure that this Sum Insured represents the full cost of rebuilding your property? (vist http://abi.bcis.co.uk for more details) | | |
| Have you had any Claims on your building insurance in the last 5 years? If so please specify below: | | |
| Please provide a description of the claim, the claim amount and the year that the claim(s) was made: | | |
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| Required Contents Sum Insured: | | |
| Have you any item(s) of jewellery, precious stones, articles of gold or other precious metals, furs, pictures, works of art and collection of stamps, coins or metals worth more than £2000 in the home? If so, please specify below: | If any items are over £2,000 in value and are not specified, they will not be covered by this policy | |
| Description and value of specified item(s) | | |
| Personal Effects Sum Insured (optional cover - please complete, if required) | | |
| If you require cover for any one single article which is normally worn, used or carried outside the home by you or your family, and is individually worth more than £2000, please specify below: | Within this option, cover is automatically provided for all personal effects away from the home, as long as they are within the personal effects Sum Insured, subject to policy Terms & Conditions, and do not have a value of £2,000 or above individually | |
| Description and value of specified article(s): | | |
| Have you made sure that these sums insured represent the full cost of replacement of your contents and personal effects? | | |
| Have you had any claims on your contents in the last 5 years? If so please specify below: | | |
| Please provide a description of the claim, the claim amount and the year that the claim(s) was made: | | |
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| Credit History Declaration | | |
| Have you, or any person living with you, ever been or have reason to expect to be: | | |
| Bankrupt, insolvent or subject to a CCJ? | | |
| Director of a liquidated company?: | | |
| Had an application for insurance refused, policy cancelled by the issuer, renewal terms and conditions imposed? | | |
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| When during the day is the best time to call you about this quote request? (Our office working hours are Mon - Fri: 08.30 - 17.30) | | |
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