Property Insurance Quote

Firstname *

Lastname *

Home Phone Number *

Work Phone Number *

Email Address *

Best Time To Contact Me *

Mailing Address (PO BOX) *

Physical Location *

Coverage Amount *

Principal Owner *

Policy *

Buildings and Contents

Sum Insured *

Number of Outer Walls *

Number of Inner Walls *

Number of Windows *

Number of Roofs *

Number of Floors *

Number of Storeys *

Are the buildings and or out buildings within 20ft of another building *

Yes

No

How is it constructed? *

For what purpose is it used? *

Is any business/ profession/ trade carried on in the dwelling or in any portion of the premises of which the dwelling forms a part? *

Yes

No

How old is the building *

Year built / renovated *

How big is the building (Sq ft) *

Details of burglary protection *

Are the Buildings in a good state of repair and will they be so maintained? *

Yes

No

Premises Occupied by *

Insured

Uninsured

What is the occupancy type? *

For how many days (consecutive) will the dwelling be left without an inhabitant in any one year? *

Number of Tenants, lodgers, boarders or paying guests *

General Contents - Value *

Electronic Equipment (Television sets, DVD players, Stereos, Internal Satellite) Value: (Break-down required) *

Computer Equipment Value: (Break-down will be required) *

Jewellery Value: (Valuation will be required) *

Coverage Type *

Local

Worldwide

Has any Company or Insurer, in respect of any of the contingencies *

Declined to insure you

Required special terms to insure you

Cancelled/refused to renew your insurance

None of the above

If YES, please give full particulars *

Have you any other policies in force covering any of the contingencies to be insured against? *

Yes

No

If YES, please give full particulars *

Have you sustained any losses during the past 3 years? *

Yes

No

If YES, please give full particulars *

Property Quote

Buildings and Contents