Home Contents & CollectionsStep 1 of 714%Broker Name* First Last Telephone Number*Email Address* Insured DetailsName* First Last Occupation / Industry*Date of Birth* DD MM YYYYSpouse / Partner NameName First Last Occupation / IndustryDate of Birth DD MM YYYYIf occupation is director or similar, state company name/nature of businessCompany NameIndustryProperty DetailsAddress* Street Address City County / State / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Is this your Main Residence?YesNoPlease specify your main addressProperty Type*Select Property TypeDetachedSemi-detachedFlatLink-detachedTerracedEnd terraceProperty in good state of repair?*YesNoPlease provide additional informationBuild Date (year)*Listed Status (if applicable)*Years lived at current address*Construction of brick, slate, stone or tiles?*YesNoPlease provide additional informationNormally occupied daily?*YesNoUsed for business purposes?*YesNoPlease provide additional information*Free from flooding, subsidence, cracking, landslip or heave?*YesNoPlease provide additional information*If any repairs/monitoring for such damage due to subsidence, heave or landslip have been undertaken, settlement or movement, please provide a copy and or the property has been subject to survey which mentions additional information.Does the property have a basement?*YesNoConfirm use i.e. gym, wine cellar etc.*ProtectionsAre all ground floor and upper accessible windows fitted with a key?*YesNoAre all external doors fitted with 5 lever mortice deadlocks?*YesNoIs an approved burglar alarm fitted?*YesNoWhat fire protections are in place?*Fire ProtectionBattery OperatedMains WiredCentral StationNoneTypes of alarm signalling (burglar and fire)*Alarm SignallingBells / SirenDigital CommunicatorPaknetRedcareOtherNoneSafe Manufacturer / Model*Cash / Jewellery Rating*Type of Safe (wall safe, floor safe etc.)*Other InformationProperty open to the public?*YesNoPlease provide additional information.*Number of domestic employees at the insured locationIs the property likely to be refurbished within the next 12 months using external contractors?*YesNoPlease provide additional information.*Has the insured or anybody residing with the insured...Had any loss or damage during the last 5 years (whether claimed or not)?*YesNoPlease provide additional information*If any repairs/monitoring for such damage due to subsidence, heave or landslip have been undertaken, settlement or movement, please provide a copy and or the property has been subject to survey which mentions additional information.Had insurance declined, refused, cancelled or special terms imposed?*YesNoPlease provide additional information*If any repairs/monitoring for such damage due to subsidence, heave or landslip have been undertaken, settlement or movement, please provide a copy and or the property has been subject to survey which mentions additional information.Been convicted or charged with any offence (other than driving offences) or entered into arrangements with creditors been declared bankrupt or been awarded a CCJ?*YesNoPlease provide additional information*If any repairs/monitoring for such damage due to subsidence, heave or landslip have been undertaken, settlement or movement, please provide a copy and or the property has been subject to survey which mentions additional information.Cover RequirementsExcess required for policy*£500£1,000£2,500OtherDo you hold this case?*YesNoName of current insurer*Inception / Renewal date*Target Premium*Sums InsuredSpecified items over £20,000 (or the selected single article limit) must be listed individually with the market value. The list must be submitted to us or retained by you, and will be required in the event of a claim.HouseHouse (£)Other permanent structure (£)Contents(Give current cost as new)Contents (£)Contents left in open (£)CollectionsPaintings, pictures, sketches, prints etc. (£)Paintings SpecifiedPaintings UnspecifiedAntique furniture (£)Antique Furniture SpecifiedAntique Furniture UnspecifiedGold, silver and precious metals (non-jewellery)Gold SpecifiedGold UnspecifiedFragile ItemsFragile Items SpecifiedFragile Items UnspecifiedClocks and mechanical artClocks and Mechanical Art SpecifiedClocks and Mechanical Art UnspecifiedNon-fragile statues and sculpturesStatues and Sculptures SpecifiedStatues and Sculptures UnspecifiedGunsGuns SpecifiedGuns UnspecifiedMusical InstrumentsMusical Instruments SpecifiedMusical Instruments UnspecifiedWineWine SpecifiedWine UnspecifiedOther ItemsOther SpecifiedOther UnspecifiedJewellerySpecified JewelleryProvide ListUnspecified JewelleryJewellery to be insured in safe ONLY at insured locationProvide ListJewellery/watches to be insured in bank/safe deposit ONLYPlease specify other itemsValue of jewellery worn dailyName of Bank / Safe depositAddress of Bank / Safe deposit Street Address City County / State / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Additional informationPlease provide any additional information that may help us in underwriting this risk, including details relating to lifestyle and risk management of this client.
