Residential Buildings Insurance Quotation Form

Your Details

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Comment: Leave this field comment blank:

Company Name*:
Contact Name*:
Contact Telephone Number*:
Contact Email:
Website*:
Postal Address*:
Proposers Details
Proposers Name:
Renewal Date:
Target Premium*:
Sum Insured (rebuilding costs)*:
Name:
Telephone Number:
Any other comments:
Declared Value*:
Current Insurer*:
Property Insured Address*:
Postcode*:
How old is the property*:
Purpose built or Converted*:
Conversion Date*:
No of Buildings*:
No of Storeys*:
No of Flats*:
Construction
Walls*:
Floor and Stairs*:
Roof*:
Occupied as i.Holiday homes? ii. Bedsits/student accommodation? iii. Hostels?*:	YesNo
Affected by subsidence, ground heave, landslip, storm or flood?:	YesNo
Abnormally exposed to Storm or Flood?*:	YesNo
Any alterations planned in the next twelve months?*:
Are there any Communial Facilities? i.e. Lift, Boilers, Tennis Courts, Swimming Pools?*:	YesNo
Any Commercial Occupancy? i.e. Shops, Offices, Restaurants?*:	YesNo
Have you been refused insurance or had special terms/conditions imposed?*:	YesNo
Have losses or claims been suffered in the last 3 years? (Provide details):	YesNo
If you have answered YES to any questions please provide details in the box below, or use for any additional comments:
Verification:	6 multiply 4 =  Fill in the result

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