Quote Form Step2 - Kounnis Insuforce Ltd.

THE PROPOSER

Title

First Name

Surname

Date of Birth

Telephone Number

Marital Status

Employment Status

Occupation

Industry

SPOUSE / PARTNER / OTHER INTERESTED PARTY

Title

First Name

Surname

Date of Birth

Telephone Number

Marital Status

Employment Status

Occupation

Industry

COVER REQUIRED / DETAILS ABOUT YOUR HOME

What type of cover do you require?

Buildings &
Contents

Contents
only

Buildings
only

How much do you want to Insure your Buildings for? (This is the cost to rebuild your property)

Do you require accidental damage cover to the Buildings?

Yes No

How much Contents cover do you require?

Do you require accidental damage cover to the Contents?

Yes No

Do you require cover away from the home for your personal belongings? (Unspecified items single article limit £1500)

Yes No

How much cover do you need?

Do you require cover away from the home for any items individually worth more than £1500? (Specified items - Valuations may be required)

Yes No

Type of item

Brief Description

Value

Add another item

Do you have any items of jewellery or valuables inside the home worth more than £1500?(For items not taken away from the home. We can note that these items form part of your contents, at no extra cost)

Yes No

Type of item

Brief Description

Value

Add another item

Full Risk Address and Postcode

What type of property is it?

Approximately, what year was the property built?

How many bedrooms does the property have?

What are the external walls built from?

What is your roof made of?

What percentage of the roof, if any, is flat?

How many adults reside at the property?

Is the property listed or does it have any historical interest?

What is the ownership status of the property? If mortgaged, please note name of mortgagee

What is the current market value of the property?

Have you or anyone residing with you suffered any claim, loss, damage or liability within the last 5 years in connection with the home, it's Contents or your personal possessions?

Yes No

PLEASE PROVIDE US WITH FULL DETAILS

Loss Date

Loss Description

Amount Claimed

Add another claim

Are all external doors either fitted with five lever mortice deadlocks, which conform to British Standard BS3621 or a multi-point locking system with a minimum of three dead bolts?

Yes No

Other Type of Lock, please state

Are any French windows fitted with either key operated security bolts at the top and bottom of each leaf in addition to the central lock or a multi-point locking system with a minimum of three dead bolts?

Yes No No French Windows

Are all ground floor and easily accessible upper floor windows fitted with key operated window locks?

Yes No

Is an intruder alarm installed?

Yes No

Do you wish to provide us with any further information?

How do you wish to be contacted with your quotation?

Phone Email

It is important that what You have told us is correct and that You have clearly disclosed all material facts which You, Your senior management and/or persons responsible for arranging the Policy knew or ought to have known. This quotation is subject to terms, conditions and exclusions.

Waltham Forest Insurance Quotation Form