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HOME INSURANCE APPLICATION

This form is designed to capture the information on which the contract of insurance will be based. All information you provide must be true and correct to the best of your knowledge and belief. Any information that is likely to influence insurers in the assessment or acceptance of your application, such as intended unoccupancy of your home, must be disclosed. If you are in any doubt as to whether a fact is relevant you must disclose it. Please note: you may skip sections of the form but the overall process will be smoother the more information you can give us.

1. Proposer details

2. Joint Proposer details

3. Cover requirements

4. Previous history

5. Property details

6. Sums insured

7. Protections

8. Claim history

Title
First name
Surname
Date of birth
Occupation (Full description, if Company director state business nature)
Telephone number
Email address
Postal address

Title
First name
Surname
Date of birth
Occupation (Full description, if Company director state business nature)

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Current insurer

Inception / Renewal date

Target premium

Excess required for policy

Other

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Have you or anyone living with you at the premises to be insured;

Ever had a proposal for insurance declined

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Ever had a renewal refused

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Ever had an insurance cancelled or declared void

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Ever had any special terms or conditions imposed

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Ever been convicted for any non-motor criminal offences

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Been cautioned for or charged but not yet tried for any non-motor offences

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Risk address
Postal code
Property type
Flat / Apartment floor
Residence
Listed
Number of bedrooms
Number of bathrooms
Year of build

Has a risk appraisal survey previously been undertaken at the premises?

Interested party details
Number of adults that live at the address
Number of children under 18 who live at the address
How long have you lived at the risk address
How long have you held buildings or contents insurance for

Material facts (Relevant information that may influence the insurer in the acceptance of this insurance)

Are the buildings in good condition and repair?

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Are any business activities conducted on the premises?

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Are any works planned or currently conducted on the premises?

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Will any buildings at the premises will be unoccupied for MORE that 30 consecutive days

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Are the buildings at the premises built of standard construction i.e. built of brick/stone/ concrete and pitch roofed with slate, tile, concrete, asphalt or incombustible mineral material

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Have buildings previously suffered damage from subsidence, landslip or heave or have any sign of damage to them that may be due to subsidence, landslip or heave (such as external cracks)

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Have the buildings been subject to survey which mentions settlement or movement

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Have the buildings or grounds been flooded or have any special exposure to flood or storm

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Are buildings located within 250metres of a site of excavation, watercourse or a body of water

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Are buildings at the premises occupied during the day

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Is any part of the building thatched

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Are buildings occupied solely by you or any other family member

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Are there any trees within 7m (20 ft) of the property, (whether inside or outside your premises) which are more than 3m (10 ft) tall

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Buildings

House (Cost to rebuild)

Other permanent structure

General contents (Give current costs as new)

Fine art and collections

Furs
Paintings, pictures, sketches, prints etc
Books
Gold, silver and precious metals (non-jewellery)
Fragile items
Clocks and mechanicals arts
Non-fragile statues and scriptures
Guns
Antique furnitures
Wine
Other items (please specify)

Jewellery / Watches only

Total jewellery amount

All specified items above the single article limit of £15,000 for Fine Art and £5,000 for Jewellery must be listed individually with the current market value in the space provided below.

Item

Current market value

Name and address of bank / safe deposit

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General security

Are all final exit doors fitted with 5 lever mortice deadlocks

Additional information

Are all ground floor and upper accessible windows fitted with key operated window locks

Additional information

Alarm

Is there an alarm at the property

Type of signalling

Is the alarm approved and maintained?

How often is the alarm maintained?

Fire protections

What fire protections are there in place

Is there a maintenance contract in place

Safe

Is there a safe at the property

Make and manufacturer

Cash / Jewellery rating

Type of safe

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If you or anyone whose property is to be insured has sustained any loss, damage or liability for any events that you wish to insure against, whether insured or not, in the last five years, please give details below.

Date of claim
Description of claim
Where did the incident happen?
Amount
Status

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Please come back on desktop or tablet to complete this form.

HOME INSURANCE APPLICATION

1. Proposer details

2. Joint Proposer details

3. Cover requirements

4. Previous history

5. Property details

6. Sums insured

7. Protections

8. Claim history

Buildings

Contents

Fine art and collections

Jewellery / Watches only

General security

Alarm

Fire protections

Safe

INSURANCE TAILORS