Landlord Residential 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. Where you require a quote for more than one property please complete our general enquiry form or ring us. Fields marked with an * are required.

Policyholder(s) Name(s) / Company Name*

Contact Name (if different from above)


Date of Birth(s)*

Marital Status*

Correspondence Address

House / Building Number or Name*

Street Address*

Postal Town*


Post Code*

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

Any Time 9am - Noon Noon - 3:00pm 3:00pm - 6-00pm

Risk Property Details

House Number or Building Name*



Local County

Postal Code*

Year Built Approximatley*

Number of Bedrooms

1 2 3 4 5 6

Number of Bathrooms

1 2 3 4 5 6

Property Type*

If Flats - How Many in Block?

Listed Building

Yes No

Wall Construction*

If others please give details

Pitched Roof

Yes No

Type of Pitched Roof

If others please give details

Flat Roof

Yes No

Flat Roof Percentage

Flat Roof Type

If other please give detail

Floor Construction*

Number of Occupants

1 2 3 4 5 6 7 plus

Type of Tenant*

If Unoccupied state how long the property has been unoccupied and your intentions for property

How long property owned

1 2 3 4 5 5 plus

Is the property in an area with a history of flooding?

Yes No

Has the premises had an Electrical Installation Inspection during the last 5 years by a qualified person?

Yes No

Type of Heating at the Premises*

Cover Details

Re-build cost of buildings £*

Cover Required*

Accidental Damage cover may not be available for certain occupancy types

Property Owners Liability*

Annual Rental Income £*

Optional Covers

Landlords Contents Required

Yes No

Value of Landlords Contents £

Is Terrorism Cover Required?

Yes No

Is cover for Malicious Damage by tenants required?

Yes No

Is cover for Theft by Tenants required?

Yes No

Do you require Legal Expenses cover?

Yes No

Claims Details

How many claims in the last 5 years

0 1 2 3

Brief details of claim(s) and date(s)

Current Insurance Details

Who are your current Insurers?*

What is the renewal date of your current policy?*

Years Continuously Insured

1 2 3 4 5 6 plus

What is your renewal / expiring premium? £*

Your History

Have you or any person to be insured ever had a policy cancelled, refused renewal or special terms imposed?

Yes No

Have you or any person to be insured been convicted of any criminal offence including theft, fraud or dishonesty?

Yes No

Have you or any person to be insured ever been declared bankrupt, insolvent or subject to an IVA?

Yes No

Have you or any person to be insured been a director of any company or organisation that has gone into liquidation, administration or receivership or been disqualified from being a director?

Yes No

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