Home Insurance Quotation Form

Please complete as much of this form as possible as it will allow us to provide you with the most competitive quotation. Fields marked with an * are required.

Your Details

Full Name(s) of Policyholder(s)*

Date of Birth(s)*

Marital Status*


Does Anyone at the Property Smoke

Yes No

Telephone Number*

Email Address*

Best Method to Contact You

Contact Me By

Telephone E-Mail

If by Telephone Please Select

Best Days

Monday Tuesday Wednesday Thursday Friday Saturday Any Day

Best Time

Anytime 9:00am - Noon Noon - 3:00pm 3:00pm - 6:00pm

Property Details

House Number or Name*

Street Address*

Postal Town*


Post Code*

Year Built Approximately*

Number of Bedrooms

1 2 3 4 5 6

Number of Bathrooms

1 2 3 4 5 6

Type of Property*

Wall Construction

Brick Stone Other

If other give details here

Pitched Roof

Yes No

Pitched Roof Type

Tile Slate Metal Concrete Other

Flat Roof

Yes No

Flat Roof Percentage*

Flat Roof Type

Felt on Timber Concrete Other

Mortgage on Property

Yes No

Details of Occupants

Number of Occupants

1 2 3 4 5 6 7

How many aged under 18

0 1 2 3 4 5 6

How long at this address?*

Claims and Cover Details

How Many Claims in the last 5 years

0 1 2 3 4 5 5 plus

Please give brief details of any claims

Total Cost to rebuild your Home £*

Building Cover Required?

Reinstatement Plus Full Accidental Damage

Total Replacement Value of Your Contents £*

Contents Cover Required?

New for Old Plus Full Accidental Damage

Do you require cover for articles away from the home?

Yes No

If Yes give dtails of items

Insurance History

Is this your first property?

Yes No

Years Continuously Insured*

What is your current / expiring premium? £*

How do you pay your premium?

Monthly Annualy

What is the renewal date of your current policy, if known?*

Name of your current / last insurer?*

Please enter the phrase as it is shown in the box above.