For a quotation on your home insurance, please complete the following form. Please note that all quotations provided are subject to the completion of a satisfactory application form.

Title:
Forename:
Surname:
Email:
Address:
Town:
County:
Postcode:
Tel (Home):
Tel (Work)
Date of Birth:
Occupation:
Property Type:	Please Select... Main Residence Second Home Let
Construction:
Have you had any claims in the last 5 years?	Yes No
If yes, details:
Any history of flood or subsidence?	Yes No
If yes, details:
Inception Date:
Buildings Sum Insured:	£
Contents Sum Insured:	£
Possessions Sum Insured:	£(single articles over £1000)
Thatch Questions
Property type:	Please Select... detached semi detached end terrace mid terrace
Type of roofing material used:	Please Select... Water Reed/Norfolk Reed Combed Wheat/Devon Reed Long Straw Fibre Thatch Other
Depth of Thatch:	Please Select... Less than 1m 1m - 2m Over 2m
How are the chimney(s) utilised:	Please Select... Central Heating Open Fires Solid Fuel Stoves
Has the chimney been swept in the last 12 months? Yes No
The chimney lined to the:	Please Select... Woodburner Open Fire None of Above
What height is the chimney above the ridge?	Please Select... Less than 1m 1m - 1.8m Over 1.8m
Do you have spark arrestors? Yes No
Are open fired or solid fuel stoves used? Yes No
How far is the nearest Fire Brigade?	Please Select... Less than 5 miles Between 5 and 10 miles Over 10 miles
Has the electrical wiring been checked by an NICEIC qualified electrician last 10 years? Yes No
Do you have a fire alarm linked to a monitoring system? Yes No
Does the property have a 60 minute Fire barrier/Thatchbatts? Yes No
Has the property had:	Please Select... Chimney Liner Inspected CCTV up the Chimney
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