You Have No Convictions (Except Motoring)

COUNTY INSURANCE SERVICES LTD HOUSEHOLD ENQUIRY FORM Contact Name: Email: Telephone: Client Details: Security Details: Name: Date of birth: Is the property in a neighbourhood watch area? Please select Occupation: Is there a NSI/SSAIB alarm? Please select If yes: (if joint) Name: Date of birth: Is the alarm covered by an annual maintenance agreement? Please Occupation: select Address of property you are insuring: Is there a safe? Please select If Yes, please give details: Is the property fitted with 5 lever mortice deadlocks on all exit doors and key operated window locks? Please select if no, please give details: Buildings The sum insured must represent the full rebuilding cost of Post code: your home (including the cost of professional fees and site clearance), any garages, greenhouses and other outbuildings, swimming pools, walls, gates and fences. (does not include damage caused by accident) Property Details: Main building: £ Occupancy: Please select Outbuildings and annexes: £

Type of property: Please select Total building sum insured: £

Wall Construction: Please select Is accidental damage cover required? Please select

Roof construction: Please select Contents: How much would it cost to replace the entire contents If Thatch %: (including valuables and high risk items) of your property as new? If Flat %: Contents are household goods including furniture, furnishings (such as curtains and carpets), all the items not fixed to the property. If you Grade if listed:Please select do not insure for the full amount, you may find that in the event of Year built: any loss, your claim will not be settled in full. (does not include damage caused by accident) Heating: General contents: £ Number of solid fuel stoves in the property? Outdoor items: £ Please Select Gold, silver and plate: £ If there is a solid fuel stove, please advise the chimney height Redundant jewellery, watches, & above the thatch? other valuables never worn or taken Please Select out of the property: £ Are there any open fires in the property? Stamp & coin collections: £ Please Select Fine art & antiques: £ If so, please confirm the chimney height above the thatch of each one? 1) Please Select 2) Please Select 3) Please Select Please advise all other heating types in the property?

Does the roof have a 60 minute fire barrier? Please select Are there smoke detectors on each floor? Please select Total contents sum insured: £ Is there a smoke detector in the roof void? Please select Is there an up to date electrical installation certificate? No Is accidental damage cover required? Please select Has the property any history of subsidence, heave, landslip, major fire or flooding? Please select Unspecified personal possessions (items you take out of your home) If yes, please provide details: (single article limit £2,500): £ Specified personal possessions over £2.500 (items you take out of Does anyone work from home? Please select your home) Please state nature of work and number of visitors; £ £ £ Pedal cycles (up to £500 total): £ Policy Excess: Specified cycles (over £500) There is a compulsory excess of £100 on main residence and £ £250 on all others. Other information: Voluntary excess in addition: Are you planning any building works? Please select Building: Please select Contents: Please select If yes, please provide details: Any claims in the last 5 years? Please select If you cannot confirm that:- If yes, please provide details:  insurance has never been declined,  you have never been declared bankrupt,  you have no convictions (except motoring), please provide details:

Current insurer? Renewal date? Target premium: £ TEL: 01865 844980 Fax: 01865 841147 Email: [email protected] County Insurance Services limited (08411634) is Authorised and regulated by the Financial Conduct Authority (FRN: 597267) V:2017