You Have No Convictions (Except Motoring)

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 NoYes
Occupation: / Is there a NSI/SSAIB alarm? Please select NoYes If yes:
Is the alarm covered by an annual maintenance agreement? Please select NoYes
(if joint) Name: Date of birth:
Occupation:
Address of property you are insuring:
Post code: / Is there a safe? Please select NoYes 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 NoYes if no, please give details:
Buildings The sum insured must represent the full rebuilding cost of 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: £
Outbuildings and annexes: £
Occupancy: Please select Main residenceHoliday/second propertyHoliday LetProfessional letPart letUnoccupiedOther (please provide details
Type of property: Please select House semi-detachedHouse end terraceHouse mid terraceFlatPark home (or the like)Other (please provide details)Bungalow detachedHouse detachedBungalow semi-detachedBungalow end terraceBungalow mid terraceBarn conversion 9or the like) / Total building sum insured: £
Wall Construction:Please select BrickCobStoneTimberWattle & daubTimber frameOther (please provide details) / Is accidental damage cover required?Please select NoYes
Roof construction:Please select Corrugated sheetFlat (Asphalt) Thatch (water reed)Thatch (long straw)Thatch (Wheat straw)Thatch 9type unknown)TileSlateOther (please provide details)
If Thatch %:
If Flat %: / Contents: How much would it cost to replace the entire contents (including valuables and high risk items) of your property as new? Contents are household goods including furniture, furnishings (such as curtains and carpets), all the items not fixed to the property. If you do not insure for the full amount, you may find that in the event of any loss, your claim will not be settled in full.
(does not include damage caused by accident)
Grade if listed:Please select Grade IGrade II (*)Grade IIGrade III
Year built:
Heating:
Number of solid fuel stoves in the property?
Please Select012
If there is a solid fuel stove, please advise the chimney height above the thatch?
Please SelectLess than 1m1m - 1.8m1.8m+
Are there any open fires in the property?
Please SelectYesNo
If so, please confirm the chimney height above the thatch of each one?
1)Please SelectLess than 1m1m or above 2) Please SelectLess than 1m1m or above 3) Please SelectLess than 1m1m or above
Please advise all other heating types in the property? / General contents: £
Outdoor items: £
Gold, silver and plate: £
Redundant jewellery, watches, &
other valuables never worn or taken
out of the property: £
Stamp & coin collections: £
Fine art & antiques: £
Does the roof have a 60 minute fire barrier? Please select NoYes
Are there smoke detectors on each floor? Please select NoYes / Total contents sum insured: £
Is there a smoke detector in the roof void? Please select NoYes
Is there an up to date electrical installation certificate?
NoYesPlease select
Is accidental damage cover required? Please select NoYes
Has the property any history of subsidence, heave, landslip, major fire or flooding? Please select NoYes
If yes, please provide details:
Unspecified personal possessions (items you take out of your home) (single article limit £2,500): £
Specified personal possessions over £2.500 (items you take out of your home)
£
£
£
Does anyone work from home? Please select NoYes
Please state nature of work and number of visitors;
Pedal cycles (up to £500 total): £
Specified cycles (over £500)
£
Policy Excess:
There is a compulsory excess of £100 on main residence and £250 on all others.
Voluntary excess in addition:
Building: Please select £100£250£500£1,000 Contents: Please select £100£250£500£1,000
Other information:
Are you planning any building works? Please select NoYes
If yes, please provide details:
Any claims in the last 5 years? Please select NoYes
If yes, please provide details: / If you cannot confirm that:-
  • 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:
County Insurance Services limited (08411634) is Authorised and regulated by the Financial Conduct Authority (FRN: 597267) V:2017