Country Heritage Insurance Agency



Heritage Insurance Agency

QUOTATION REQUEST FORM – Cherished

TEL: 01787 229200 Fax : 01787 229053 Email : info@heritageinsuranceagency.co.uk

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Has the insured or a family member ever been declined insurance or been convicted of any criminal offence or been declared bankrupt Yes / No

Proposers Name:

Date of Birth :

Address of property to be Insured:

Postcode:

Do you reside in the UK Yes / No

Is the property main residence Yes / No

Second Home Yes / No Holiday Let Yes / No

Prof Let Yes / No Unoccupied Yes / No

Agency No:

Agents Name & Address if applicable:

Telephone:

Fax No:

Construction of Property:-

Walls:

Roof: Flat Roof %

Year property built:

Is the property listed ? Yes / No (if yes please state grade)

Grade II Grade II* Grade 1

Proposers Occupation:

Target Premium:

Current Insurer:

Target Premium :

Renewal Date

Contact Name:

Is the property Detached [pic] Semi Detached [pic] Terraced [pic] Other (please give details) [pic]

Has the property ever suffered from subsidence, ground Heave or Landslip YES / NO

Has the property ever suffered flooding or in an area which has been flooded YES / NO

Has the Property any Trees within influencing distance of the property YES / NO

Is the Property having any Structural renovation works, being refurbishment or being re-decorated YES / NO

If Yes Please provide details of works to be carried out:

Is planning permission required for the changes being made ? Yes / No Has planning permission been sought ? YES / NO

Has planning permission been granted ? Yes / No Estimated costs of works £

Does the property have minimum security YES / NO

Does the property have an alarm YES / NO

Does the property have a woodburning stove YES / NO If yes is the chimney professionally lined YES / NO

Does the property have a Multi fuel stove YES / NO If yes is the chimney professionally lined YES / NO

Does the property have a open fire YES / NO Central Heating Only YES / NO

Claims History / Other relevant information (if none please state NONE):

Date:

Voluntary Excesses (please tick excess required which is in addition to the £50.00 policy excess):

Buildings: £100 5% Discount £250 [pic] 7.5% Discount £500 [pic] 10% Discount £1000 [pic] 15% Discount

Contents: £100 [pic] 5% Discount £250 [pic] 7.5% Discount £500 [pic] 10% Discount £1000 [pic] 15% Discount

Buildings Sum Insured: £ STANDARD COVER / INC ACCIDENTAL DAMAGE

Contents Sum Insured: £ STANDARD COVER / INC ACCIDENTAL DAMAGE

Personal Possessions - Unspecified Items: £

Unspecified Sports Equipment: £

Specified Items: £

Number of Unspecified Cycles (upto £500):

Specified Pedal Cycles (over £500): £

Money Cover: £

Portable items & Mobile Phones £

Items held in Bank: £

Family Legal Protection: YES / NO

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