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Central Insurance Services Home and Drive Quote Form

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Proposers Full Name :

Proposers Contact Telephone Number :

Proposers Email Address :

Proposers Date Of Birth :
(dd/mm/yyyy)

Proposers Occupation :

Proposers Address :

Proposers Postcode :

Joint Insured Full Name

Joint Insured DOB

Joint Insured Occupation

Buildings rebuild cost (£) :

Contents Total (£) :

Personal Possessions / All Risks (Items under £2,500) :

Specified items over £2500 :

Type of property :

Use :

Year or Decade of Construction :

Number of bedrooms :

Previous Claims

Is the final exit door secured by a deadlock conforming to BS3621 or with a minimum of 5 lever or alternately a multi point locking system which incorporates a lever or deadlock which is capable of being secured by a key from both sides of the door?

Are all other external doors protected by a deadlock conforming to BS3621 or with a minimum of 5 lever or key operated security bolts operating horizontally internally top and bottom or a multi point locking system which incorporates a lever or cylinder deadlock which is capable of being secured by a key from both sides of the door?

Are the opening ground floor windows secured by a key operator window locks

Are all accessible upper floor windows secured by key operated window locks

Is your home protected by an alarm system

If YES : is it under a maintenance contract by an NSI or SSAIB company

Which Signaling method is used

Travel:

What travel insurance do you require ?

is any applicant aware of any sign or sympton for which they have not yet consulted a doctor?

Is any applicant awaiting in-patient, day-patient or out-patient treatment?

Has any applicant received in-patient, day-patient or out-patient treatment in the last 12 months?

Any additional information :

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+44 (0)1224 656623

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