| 1.
Personal Details |
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| Title: |
|
| First Name |
|
| Surname |
|
| Date of Birth |
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| E-Mail Address |
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| Phone Number |
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| Address 1 |
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| Address 2 |
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| County |
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| Dublin Post code (if applicable) |
|
| 2. Property Details |
|
| Type of Dwelling |
|
| Number of Bedrooms |
|
| Is the property let to a tenant? |
Yes
No |
| if "yes", please state type of tenant |
|
| Number of Individuals in the property ? |
|
| If "no" please state type of Occupancy |
|
| If Not Main Residence, please provide a Correspondence address |
|
| Address 2 |
|
| County |
|
| Dublin Post code (if applicable) |
|
| Year of Construction |
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| Number of years living in property |
|
| Are there locks on Windows and Doors ? |
Yes
No |
| Roof Construction |
|
| % of Roof flat /not standard |
|
| 3. Security Details |
|
| Alarm Fitted |
Yes
No |
| if "yes", is it NSAI approved ? |
Yes
No |
| Connected to central station |
Yes
No |
| A minimum of 2 Smoke Detectors |
Yes
No |
| 4. Previous History |
|
| Current Insurer |
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| Renewal Date |
|
| 5. Requirements |
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| What is the required sum insured on your building (re-building cost)? |
|
| What is the required sum insured on your contents |
|
| Do you require all risks cover on your valuables and personal effects outside
the home. |
Yes
No |
| If "Yes" state the amount of cover |
|
| Have you had any claims in the last 5 years? |
Yes
No |
| If "Yes" please give details |
|
| This form is for quotation purposes only and is not confirmation of a quote
or insurance cover. Insurance cover will only commence on receipt of a completed proposal form, payment and written confirmation from ourselves. |
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