Household and Property Insurance

Application Form

Please tick YES/NO boxes where appropriate.

Name

Email Address

Daytime Telephone Number

Address

Post Code

Your Details

Your Date of birth

Occupation

Employer's business

Spouse (if applicable)

Date of birth (dd/mm/yyyy)

Occupation

Employer's business

Buildings

Is accidental damage cover required? Yes No

Sum Insured

Contents

Is accidental damage cover required? Yes No

Sum Insured

Of which valuables

Specified Items (over £1000)

Freezer cover

Sum Insured

Is The Property

Your main residence (and not let)? Yes No

Used for business purposes? Yes No

Standard construction? Yes No

Free from subsidence? Yes No

Type (i.e detached house, semi-detached etc)

Year built Number of bedrooms

All risks [items away from home]

	Unspecified	Specified Items (Over £750)
Sports equipment
Furs
Photographic Equipment
Valuables
Clothing
Personal Effects
Pedal Cycles
Money/Credit cards

Additional Info

Previous Insurer

Renewal Date (dd/mm/yyyy)

No Claims Discount (years)

Approved Locks Yes No

Approved alarm Yes No

Neighborhood watch scheme Yes No

Smoke detector Yes No

Previous Claims

Any Claims in last 5 years? Yes No

Amount

Date (dd/mm/yyyy)

Circumstances

© 2003 - 2010 CBG Insurance Brokers Ltd. All rights reserved.
Authorised and Regulated by The Financial Services Authority (FSA), Firm Reference Number 307046.
Registered Office: Southmoor House, Southmoor Road, Manchester. M23 9XD.
Registered in England and Wales, number 4192327