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Insurance Quote Form it doctor

YOUR DETAILS:

Title

Title Other

First Name

Last Name

Date of Birth

Occupation

Daytime Phone Number

Evening Phone Number

Mobile Phone Number

Best Contact Time

Email Address

YOUR CORRESPONDENCE ADDRESS:

Address Line 1

Address Line 2

Address Line 3

Postcode

PROPERTY TO BE INSURED ADDRESS:

Property address to be insured (if different from above)

Property address to be insured 2

Property address to be insured 3

Property Postcode to be insured

PROPERTY TO BE INSURED DETAILS:

Property construction

Property type

Year property built

Number of bedrooms

Percentage roof thatched

Other roofing materials if not 100% thatched

Type of thatch

Is any part of the roof flat

Date thatch last inspected by thatcher

Date last rethatched

Date last reridged

Listed building status

Is this a new purchase?

Date cover required from - Buildings

Date cover required from - Contents

Property use

Outbuildings?

Outbuildings details to include type of outbuilding and the construction details of the walls and roof

Swimming Pool?

Hot Tubs or Jacuzzi?

What is the full cost of rebuilding the property including all outbuildings, with a cost breakdown if possible?

Do you require accidental damage cover for Buildings?

Do you require accidental damage cover for Contents?

Contents sum to be insured*

Do you require cover for individual items valued at under £2,000 away from home. This applies to Main Residence only

Do you require cover for individual items valued over £2,000? If so itemise below. This applies to Main Residence only

Specified Items over £2,000

Have you made any claims in the past six years?

Details and dates of all claims

History of Subsidence/Landslip or Heave?

Subsidence/Landslip or Heave details

Is there a history of flooding associated with the property or the immediate area?

Flooding details

What is the distance of the property and outbuilding/s from a river, stream, watercourse or the sea?

Are there any trees or shrubs within 22 feet (7 metres) of the property or outbuildings that exceed 10 feet (3 metres) in height whether inside or outside of your boundary, of the premises or outbuildings?

Details of the height and distance of all trees from the property, including the outbuildings

HEATING:

Do you have any open fires in use, if so how many?

Number of open fires in use

When was the chimney to the open fire last swept?

Do you have a Woodburning or Multifuel stove?

How many Woodburning or Multifuel stoves?

How old is the Woodburning or Multifuel stove?

What type of liner does each stove have?

When was the chimney to the stove last swept?

How old is the stove liner?

If a flexible metal liner what type of insulation is installed to each stove?

When was the chimney last CCTV inspected for each stove??

Are spark arrestors fitted?

Number of spark arrestors

Number of Chimneys in use

Height of chimneys in use

Type of central heating

Other type of central heating

Number of smoke alarms

Smoke alarms in the roof void?

Fire extinguishers?

Number of fire extinguishers

Kitchen Fire Blanket?

Type of front door lock*

Type of rear door lock*

Other exit door locks*

Ground floor and accessible windows lockable?

Ground floor and windows lock details

Intruder Alarm fitted?

Intruder Alarm details

Intruder Alarm annually maintained?

Was a recent electrical condition report carried out?

What is the expiry date of current electrical condition certificate?

Has any insurer ever declined to provide you with insurance, imposed special terms for any insurance (such as increased flood or subsidence excess or declined flood or subsidence cover), cancelled or refused to renew any insurance? If yes please specify

Have you, or any of the people named in this proposal, ever been declared bankrupt or received any county court judgements within the last 10 years? If yes please specify

Any additional information

If you are human, leave this field blank.

Insurance Quote Form it doctor

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