Mayfair Online - Insurance Consultants

26 Oct 09

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Contact Information

How did you hear about us

Firstname:

Surname:

Home Post Code:

House Number:

Road Name:

Home Telephone No.:

Mobile Telephone Number:

Email Address:

Flood Questionnaire

Nearest Watercourse
Please advice the distance of the premises from the nearest river, stream, tidal water or other watercourse

Height Above Water
Please advise the approximate height of the premises above the normal water level of the nearest watercourse

Flood History
Please advise of any flooding incidents that you are aware of at the premises or in the immediate neighbourhood ?

Flood Defences
Please advise of of any flood defences carried or planned by you, previous tenants or the local authority ?

Property Details

Risk Post Code:

Year Built:

Bedrooms:

Property Type

Extended:

Walls:

Roof:

Listed:

Other Info:

Use / Occupancy

Type of Accommodation:

Residential Status:

Main Residence:

Unoccupied over 30 days consecutively:

Business Use:

Number of Adult Occupants:

Security

Self Contained / Lockable Entrance:

External Door Locks fitted:

Lockable Accessible Windows:

Is a smoke alarm fitted:

Is an intruder alarm fitted:

Buildings Cover

Buildings Cover Required:

Buildings Level of cover:

Building Sum Insured

Building Sum Insured:

No Claims Discount:

Interested Party:

Contents Cover

Contents Cover Required:

Contents Level of Cover:

Contents Sum Insured:

No Claims Discount:

Highest value item in the home:

Possesions & Specified Items

Specified Items

Jewellery / Watches: Total value:

Paintings & Other Art: Total value:

Fur: Total value:

Antiques & Antique Furniture: Total value:

Statues: Total value:

Collections: Total value:

Cover Away from the home

Unspecified Possessions

Cover Required:

Total Sum Insured:

Territory::

Specified Possessions

Single Items valued £1500+: Total value:

Sports Equipment: Total value:

Photographic Equipment: Total value:

Bicycles: Total value:

Policy Holder Details, Claims and Submit

Date of Birth:

Marital Status:

Uk Resident (Years):

Occupation:

Employers Industry:

Full time / Part Time:

No of vehicles at home:

Motor Renewal Month:

Claims

Number of claims:

Claim Type:

Date:

Cost:

Cover & Submit

Cover Date:

Best Quote:

Include Legal Expenses:

Include Travel Insurance:

Include Breakdown Insurance: