| Personal Details |
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| Name of Insured |
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| Date of Birth |
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| Occupation |
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| Joint Insured's |
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| Name Of Joint Insured |
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| Date of Birth |
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| Occupation |
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| Relationship to First Insured |
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| Day Time Telephone Number |
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| Home Telephone Number |
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| The Insured Property |
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| Address of the Property |
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| Postcode |
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| Period of Ownership |
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| If less than 3 Years previous residence give address and period of occupation |
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| Type of Property |
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| House |
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| Maisonette |
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| Flat |
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| Bungalow |
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| Town House |
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| Detached |
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| Semi Detached |
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| Terraced |
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| Age of Property |
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| Is the Property Listed |
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| Your Relationship to the property |
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| Landlord |
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| Owner Occupier |
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| For Rented premises |
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| Furnished |
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| Unfurnished |
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| Age of Property |
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| Number of Bedrooms |
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| Type of Cover |
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| Standard Cover |
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| Accidental Damage Cover |
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| Start Date |
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| Full Rebuilding Cost Building Sum Insured |
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| Excess |
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| General Information |
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| Have you or anyone living with you or who will be living with you |
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| made any insurance claim or sustained any building loss or contents loss damage injury or liability at this or any previous address in the past 5 years either insured or not |
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| If Yes |
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| Further Information |
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| Buildings Claim |
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| Contents Claim |
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| Other |
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| Ever had insurance declined renewal refused cover terminated or special conditions imposed by an insurer |
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| Ever been convicted or have any prosecution pending for any Criminal Offence (other than a motoring conviction) |
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| Ever been declared bankrupt |
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| Is Your Home |
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| Built of standard construction |
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| Showing Any signs of / or previously suffered subsidence landslip or ground heave and/ or in an area liable to flooding subsidence landslip or ground heave. |
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| Liable to flooding |
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| Used at weekends only or as a holiday cottage |
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| Left unoccupied for 30 consecutive days or unfurnished for 60 consecutive days |
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| Self contained with no shared access facilities and a separate lockable entrance under your control |
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| Occupied solely by you and your family |
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| Used for business purposes |
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| Are you a member of a Neighbourhood Watch Scheme |
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| Have you an alarm |
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| Are all external doors secured by a five lever mortice locks and are all accesible windows secured by security locks |
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