Insured name *
Address 1 *
Address 2
Address 3
Town/City *
Postcode *
Age of Property
No. of Storeys *
Please confirm the property has brick/stone walls and a slate/tile roof. No Yes
Floors * Wooden Concrete
Buildings Declared Value £ *
Rent Sum Insured £ *
Indemnity Period *
Contents Sum Assured £ *
Property Owners Liability £ *
Employers Liability - Wage Roll £ *
Have there been any claims in the past 5 years? If yes please tick and provide details.
Date (dd-mm-yyyy)
Type of Loss/Cause
Paid £
Outstanding £
Action take to avoid recurrence
Contact Name *
Contact Tel *
Contact Email *
How would you like to be contacted? Email Telephone
When would you like to be contacted? * (dd-mm-yyyy) Morning Afternoon Evening
Current Insurer *
Renewal Date* (dd-mm-yyyy)
Current Premium £ *
Is a terrorism quote required? No Yes
Deadline Date* (dd-mm-yyyy)
Single Property Risk Submission Form
.