Home Plan Insurance Quote Form

Title: Mr Mrs Miss Ms Dr

Name in Full:

Address1:

Address2:

Address3:

Address4:

Postcode:

Email:

Address of property to be insured if different:

Address1:

Address2:

Address3:

Address4:

Postcode:

Date of Birth - You:

Date of Birth - Partner:

Occupation/Profession - You: (inc. part time work)

Occupation/Profession - Your Partner: (inc. part time work)

If you have not lived at the above address for the past 12 months, please provide details of your previous address(es) including postcode(s) during the past 3 years.

State the date when you wish the insurance to:

Start: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036

Please Note: The first period of insurance must not be for less than 12 months unless specifically agreed.

1). Have you, your partner or any other member of your family who normally lives with you:

a). Ever been refused home insurance or had special terms imposed? Yes No

b). Sustained any other loss or damage due to theft or attempted theft during the last 4 years? Yes No

c). Sustained any other loss or damage in respect of the cover proposed during the last 4 years? Yes No

d). Had any claim made against you or them during the last 4 years? Yes No

e). Ever been convicted of arson or any other offence involving dishonesty of any kind? Yes No

2). Have you previously been insured for the risks proposed during the last 4 years without making a claim? Yes No

If Yes please state name(s) and policy number(s) of household insurers during the last 4 years.

Insurer(s):

Policy Number(s):

Please confirm that you give us authority to obtain confirmation of your previous insurance record if required. Yes No

If you have ticked Yes to questions 1a to e, or No to 2, then please give details below.

Is the Home:

1a). built of brick, stone or concrete and roofed with slates, tiles, concrete, asbestos, asphalt or metal? Yes No

b). in good state of repair and will it be so maintained? Yes No

c). close to any water course or otherwise prone to damage by flood? Yes No

d). free from any sign of subsidence, heave or landslip and not in an area which has a history of any such damage? Yes No

e). self contained, having its own personal lockable entrance under your sole control? Yes No

f). used solely as a private living accomodation for you and your family? Yes No

g). regularly left unattended as a result of all adult residents being at work, or in full time education or otherwise left unoccupied? Yes No

2). Has the home sustained any loss or damage in respect of the cover proposed or sustained any other loss or damage due to theft or attempted theft during the last 4 years? Yes No

If you answered Yes to 1c or 1g or 2, or No to 1a,b,d - f, then please give details below.

Is the home? house bungalow flat maisonette If house or bungalow, is it: semi detached detached terrace

In what year was the house built? Please note: For properties built prior to 1920 please refer to us

If pre-1920, has the home been, modernised and rewired in the last 20 years? Yes No

If No, please give details below.

No. of bedrooms, or rooms originally constructed as bedrooms: 1 2 3 4 5 6 7 8

Standard Cover - Contents

Is cover required? Yes No

Select cover required Standard Cover Accidental Damage Cover

The policy provides cover for contents up to £35,000 (to cover the FULL REPLACEMENT COST AS NEW of your home contents (Excluding articles to be insured under PERSONAL POSSESSIONS), with limits on high risk* items of i) £10,000 in total ii) £1500 any one item or collection.

Please tick the box to confirm your contents do not exceed any of the limits.

* High risk items are jewellery, precious stones, articles of gold or other precious metals, furs, pictures, works of art, stamp, coin and metal collections.

Security

Is your home fitted with door and window locks that comply with our minimum security standard?

Yes No

Security to our minimum standard is compulsory for homes in ratings districts N - U. A premium discount is available for homes in ratings districts A - M. If you have answered Yes above, do you wish to be allowed a premium discount by complying with our minimum security standard? Yes No

Please Note:

1. Minimum Level of Security

Types of Locks

A. Mortice deadlock of at lease 5 levers.

B. Mortice deadlock or Rim Automatic Deadlock which complies with British Standard 3621.

C. A comparable lock to B above approved by us.

D. Multi-point locking device with detachable key.

E. Key operated lock(s) or bolt(s) (morticed or surface mounted) at the top and bottom of the door.

F. Key operated lock(s) or bolt(s) which prevents the door being moved upwards or sideways, in addition to the manufacturers lock.

G. Key operated window locks (louvre windows must have glass glued to the frame).

2. Where a security discount is allowed, you will be required to pay the first £100 of any theft claim should you fail to implement the security.

3. Security to our minimum standard is compulsory in certain circumstances. Where this is the case, theft cover will be excluded should you fail to implement the security.

4. NSI stands for National Security Inspectorate.

Standard Cover - Buildings

Is cover required? Yes No

Select the cover required Standard Cover Accidental Damage Cover

State the sum to be insured. This must represent the full rebuilding cost of your home as new (including the cost of professional fees and site clearance) and any garages, greenhouses and other out buildings, swimming pools, walls, gates and fences. Sum Insured £

Name and Address of any mortgagee or other interest in the property.

Optional Cover - Personal Belongings

This cover is only available if you have insured contents. Is cover required? Yes No

Please Note: Pedal cycles and Specified Articles cover is only available if you insure Unspecified Articles.

A. Unspecified Articles

(Unspecified valuables, personal effects, clothing and luggage, leisure equipment and sports equipment).

This section provides cover for Unspecified Articles up to £2500 or £5000 with the following inner limits applying:

Any one single article £1000, Money £300, Credit Cards £500

Please tick the box to confirm the limit required. £2500 £5000

B. Unspecified Pedal Cycles

Is cover required for unspecified pedal cycles up to £250 each? Yes No

If Yes, how many pedal cycles do you own? No. of Cycles

C. Specified Articles/Specified Pedal Cycles

Individual items worth in excess of £1000 (but not exceeding £5000) or pedal cycles worth over £250 can be covered but must be individually specified. List such items in the space below. Evidence of value is required for all specified articles.

1. Sum Insured £

2. Sum Insured £

3. Sum Insured £

4. Sum Insured £