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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