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About You
Title	Mr Mrs Miss Ms Dr
Forename
Surname
Date of Birth
Marital Status	Single Married Divorced Common Law Widowed
Occupation
House Number / Name
Postal Code
Email Address
Phone Number (including STD Code)
Your House Details
Approx year house was built
Type	Detached Semi-Detached Terraced
How Many	Bedrooms - Rooms - Floors
Security
The property fitted with approved locks (BS3621) on all final exit doors. Other doors: Are all other doors fitted with approved locks/bolts. N/A Click Here All patio/french doors (if applicable) fitted with approved locks/bolts. The property is fitted with approved locks/bolts on all accessible windows. I/We are a member of a neighbourhood watch scheme. The property have a smoke alarm. The property fitted with an active intruder alarm?
Claims Experience
Please enter details of any claims or losses
Date Detail the type of claim i.e. Theft or Fire etc. Claim Cost 1 2 3 4
All Risks
Please detail any specified valuables you require All Risks cover for. Detail the item together with your sums insured requirement
Buildings Cover
Type	Standard Accidental Damage
Sum Insured
Previous Insurance
if Yes date expired
Date Expired
Years Claim Free
Contents Cover
type	New for Old Standard Accidental Damage
Sum Insured
Previous Insurance
If Yes date expired
Years Claim Free