Mayfair Online - Insurance Consultants

26 Oct 09

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Contact Request

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:

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: