Confidential home insurance Form

For home, building and building contents cover

* indicates mandatory fields

Tick Checkbox for Joint Policy

personal DETAILS

1st applicant Title Mr Mrs Miss Ms Dr First Name* Surname* Marital Status Please select Married Single Divorced Widowed Separated Cohabiting Date of Birth (dd/mm/yyyy) Smoker? yes no On Electoral Roll? yes no Are you a UK Resident yes no Number of Dependants

2nd applicant Title Mr Mrs Miss Ms Dr First Name Surname Marital Status Please select Married Single Divorced Widowed Separated Cohabiting Date of Birth (dd/mm/yyyy) Smoker? yes no On Electoral Roll? yes no Relationship to first applicant Please Select Husband Wife Partner Other If other, please specify

Contact details
Best phone contact number*
Best time to call*	9 - 12 a.m.	12 - 5 p.m.	5 - 9 p.m
E-mail address*
Address
Postcode
Previous address if less than 3 years at the above
Address
Postcode

your employment details

1st applicant Self Employed? yes no National Insurance Number Employer's Name How long have you worked there? Employer's Address Your Occupation Type of Employment Please Select Full Time Part Time Agency Temp

2nd applicant Self Employed? yes no National Insurance Number Employer's Name How long have you worked there? Employer's Address Your Occupation Type of Employment Please Select Full Time Part Time Agency Temp

your income
If self employed, can you supply a letter from your accountant confirming income? Please Select Yes No				How many years?
If yes,	Accountant's Name
	Accountant's Address
	Accountant's Tel. No.
Your gross annual income with overtime & bonus (if self employed net pre tax profit)			£
Your partner's gross income with overtime & bonus			£

home insurance requirements
Year Built		Number of Bedrooms
Type of Cover	Please Select Buildings and contents Buildings only Contents only	Landlord type of cover	Please Select Buildings and contents Buildings only Contents only
Type of Building	Please Select Detached Semi-detached Flat Bungalow Commercial Other if other, please specify in the comments section below.
Have you made any buildings or contents insurance claims in the last 5 years?			yes	no
When do you want the cover to start?

comments / additional information

Please tick this box if you are a Broker / Solicitor / Introducer
Full Name * Tel. No. * E-mail *