First Name
Last Name
Address 1
Address 2
Daytime Telephone
Evening Telephone
Email Address
Date of Birth:
Best time to contact:
Property Address (if different to above)
Address 1
Address 2
Additional Information
Construction of building (please give a brief outline into the construction of your property)
Is your property
Age of property
Number of bedrooms upstairs
What is the type of roof?
Is the property listed?
Buildings insurance renewal date /
Contents insurance renewal date /
Is your property
Building value (re-build cost not market value)
Contents value
All risks / Personal Possessions

Have you made any Claims in the last 6 years?

If Yes please give the amount claimed, the date of claim, reason for claim

Has the property had any history of subsidence?

landslip or heave?

If yes please give details

Is the property close to a river or stream?

If yes, how far away is it and how high is the property above the water level?

Is there any history of flooding to the property or local area?

If yes, please give details

Are there any trees or shrubs within 22 feet of the property that exceed 10 feet in height?

If yes please state height, type of tree and proximity to the property.

Do you have open fires in use?
Is the chimney lined?

Do you have a woodburning or multi fuel stove in use?

Is the chimney lined?
Is the property fitted with:

Central Heating?

If Yes, What sort?

Smoke Alarms?
Fire Extinguishers?
Spark Arresters?
Fire Blankets?
Mortice Deadlocks?
Key Operated Window Locks?
Intruder Alarm?
Has the property had a qualified wiring check?
If yes, when was this carried out?

Alternatively you can contact us direct at:


The Old Station
French Drove
Gedney Hill
PE12 0NR

Tel: 01406 330007
Fax: 01406 331185