Home, Contents & Collections"*" indicates required fieldsStep 1 of 714%Broker Name* First Last Telephone Number*Email Address* Insured DetailsName* First Last Occupation / Industry*Date of Birth* Day Month YearSpouse / Partner NameName First Last Occupation / IndustryDate of Birth Day Month YearIf occupation is director or similar, state company name/nature of businessCompany NameIndustryHas the customer been identified as a vulnerable customer (as per FCA definition)? Yes NoReason for vulnerability (If applicable):Detail tailored approach to appreciate and deal with vulnerable circumstances:Property DetailsAddress* Street Address City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is this the policyholder’s main residence Yes NoPlease specify your main addressProperty Type*Select Property TypeDetachedSemi-detachedFlatLink-detachedTerracedEnd terraceProperty in good state of repair?* Yes NoPlease provide additional informationBuild Date (year)*Listed Status (if applicable)*Years lived at current address*Construction of brick, slate, stone or tiles?* Yes NoPlease provide additional informationNormally occupied daily?* Yes No OtherUsed for business purposes?* Yes NoPlease provide additional information*Free from flooding, subsidence, cracking, landslip or heave?* Yes NoPlease 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?* Yes NoConfirm use i.e. gym, wine cellar etc.*ProtectionsAre all ground floor and upper accessible windows fitted with a key?* Yes No OtherAre all external doors fitted with 5 lever mortice deadlocks?* Yes No OtherIs an approved burglar alarm fitted?* Yes No OtherWhat 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?* Yes NoPlease 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?* Yes NoPlease 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)?* Yes No OtherPlease 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?* Yes No OtherPlease 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?* Yes No OtherPlease 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?* Yes No OtherName 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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.Δ
