Fire Insurance
Insurance Form
Personal Information
Name / Surname : * E-Mail: *
Address: U.K Address & Telephone:
Telephone No: * Owner:
Mobile No:    
Household Insurance
Building Value: £    
Pool Value : £    
Contents Value: £    
Size of Building ():       
The following risks are included in our Basic Package :
* Burst pipes 
* Flood 
Sabotage & Malicious acts of Terrorism 
Storm & Tempest 
* Fire 
Motor Vehicle Damage 
* Airplane Damage
Please tick below if you would like any of the extra included in your quotation
Third Party Liability to neighbours 
Debris removal
Marine vessel damage  
We are now pleased to be able to offer you Accidental Damage at a premium of £25.00 per annum.
Policies carry an excess of £75, with a maximum claim of £750 in any one year.
Do you wish to include Accidental Damage in your quotation?
Has any insurance declined to accept or renew insurance for you on the property now proposed for insurance?
if yes, please state details
Have you ever sustained loss by any perils proposed for insurance?
if yes, please state details
Is the amount proposed, in your opinion equal to the value of the property?
Expiry date of present insurance:
Start date for cover:
Payment type: