Household contents quotation request

To obtain a quotation, please complete this form.

Note: Please be aware that Bruce Stevenson is an independent intermediary, we currently have access to 12 major insurers for household products and are regulated by the Financial Services Authority.
Failure to supply the correct information to the questions that follow could invalidate your cover so please be sure of your answers.

Name:
E-mail:
Address:
Post Code:
Telephone No:
Date of Birth:
Occupation:
Marital Status:	married single
Occupation of Property:	Main Residence/Let out/Holiday Home etc
Is the property regularly left unoccupied?	yes no
General Questions
Have you or any other person to whom the insurance will apply suffered any incidents or losses, at these or any other premises, whether insured or not, in the last 5 years?	yes no
Have you or any other person to whom this insurance will apply ever been convicted of any criminal offence, other than driving offences?	yes no
Are you or any other person to whom this insurance will apply, aware of any circumstances which may give rise to a claim, or been refused insurance or had special terms imposed for household insurance?	yes no
How many bedrooms does your property have?
Do you currently have insurance on the Contents of your home?	yes no If yes, please advise name of insurer
Do you have a burglar alarm or safe at your property	yes no
If yes, please advise details i.e. name/model
Is this your first home?	yes no
Cover Requirements
Start Date of Insurance
Sum Insured?
Accidental Damage cover?	yes no
Business Equipment Required ?	yes no
Sum Insured?
Personal Possessions Items (such as clothing, baggage, guns, sports equipment and other similar items carried about the person)
Unspecified Sum Insured?
Maximum Value any one item