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Contact Name:
Phone Number:
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Address:
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Birth Date:
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Occupation:
Buildings Sum Insured:
£
Contents Sum Insured:
(If high risk items exceed one third, please advise)
Please tick if accidental damage cover is required:
Please tick if personal possessions away from home is required:
If ticked, please indicate maximum value:
House
Detached
Owner Occupied
Bungalow
Semi-Detached
Rented
Flat
Terraced
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Year Built:
No. of Bedrooms:
YES
NO
Is the home unoccupied for more than 30 days at a time?
Is the home unoccupied during normal working hours?
Is the house used for any business or professional purposes?
Is the house fitted with 5 lever mortise deadlocks on all final exit doors?
Is the house fitted with key operated window locks on all accessible windows?
Is the house fitted with an intruder system?
Is there any history of subsidence or flood damage to your home or in the area?
Have you suffered any loss or damage or made any claims in the last 5 years?
If yes, please supply details:
Current Insurer:
Your house insurance renewal date:
Are there any other material facts which may affect this quotation?
Additional Comments:
Do you agree that the infomation you have entered is factual?
STUART & CO, STUART HOUSE, 15 RAMSAY COURT, HINCHINGBROOKE BUSINESS PARK, HUNTINGDON, CAMBS, PE29 6FY
TEL +44 01480 433443 FAX +44 01480 431060 Email : sales@stuartandco.co.uk