| fields marked with * are required |
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| * Your Name |
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| * Your Email Address |
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| * Telephone |
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| * Name of Proposer 1 |
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| * DOB for Proposer 1 |
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day:
month:
year:
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| * Occupation of Proposer 1 |
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| * Name of Proposer 2 |
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| * DOB for Proposer 2 |
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day:
month:
year:
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| * Occupation of Proposer 2 |
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| * Risk Address |
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| * Risk Postcode |
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| * Building Sum Insured |
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| * Contents Sum Insured |
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| Year Built |
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| Listed |
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| * Property Type |
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| * Number of Storeys |
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| Total number of flats in whole building (if flats) |
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| Total number of flats to insure (if flats) |
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| If not standard construction please state type |
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| Flat Roof Area (If Applicable) |
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| * The Property is Currently |
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| If let / to be let then written tenancy agreement is / will be more than 6 months |
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Yes
No |
| If let / to be let then the landlord's agreement is / will be direct with |
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| If let / to be let then the tenant(s) are / will be |
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| If let / to be let then then what number of single unrelated persons are there / will there be |
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| If let / to be let then the tenant(s) are / will be |
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| Have you made a claim in the last 5 years |
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Yes
No |
| Current Insurers Name |
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| Current Policy Expiration Date |
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| Any other information |
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