HOME COVER - QUOTE ME

Our Privacy Statement, Terms and Conditions, Initial Disclosure Document and Terms of Business are those on which we intend to rely and for your own benefit and protection we urge you to read these carefully before proceeding. If you do not understand any point lease ask for further information.

I agree to receiving marketing information from Bridge Insurance Brokers Ltd or from selected business partners Yes No

Policyholder name

2nd Policyholder name (if joint)

Date of birth

2nd Date of birth (if joint)

Marital status

Please select Married Single Living with Partner Other

Occupation

2nd Occupation (if joint)

1st line of address to be insured

Postcode

Are you a member of the British Florist Association?

Please select Yes No Yes through Teleflorist Membership Yes through Flowers Direct Membership Yes through Flowergram Membership Yes through Flowers By Florists Membership Yes through Society

Contact Telephone Number

Email Address

What is the property ownership?

Please select Mortgaged Owned outright Private rental (unfurnished) Private rental (furnished) Housing association rental Other

Type of Property

Please select Detached House Semi Detached House Terrace House Detached Bungalow Semi Detached Bungalow Terrace Bungalow Flat above a shop Flat up to 2nd floor Flat above 2nd floor Other

Year built

Number of bedrooms

Please select 1 2 3 4 5 6

Is the property of standard construction?

Please Select Yes No, Please describe further info box
(i.e. Brick/Stone walls with Tile/Slate pitched roof)

Buildings sum insured (if required)

£

General Contents sum insured (if required)

£

Specified Items within the home / valuables (if required)

Value £ Description

Specified Items within the home / valuables (if required)

Value £ Description

Specified Items within the home / valuables (if required)

Value £ Description

Unspecified items outside of the home / personal possessions (if required)

Value £

Specified items outside of the home (if required)

Value £ Description

Specified items outside of the home (if required)

Value £ Description

Do you comply with points A-C of the minimum standards of security as shown above here?

Please select Yes No

Do you have any of the following:

Audible Alarm

Police Response Alarm

Smoke Alarm

Have there been any incidents in the last three years which have or could result in a claim?

Please select Yes No

If yes, please provide details:

Date:

(dd/mm/yyyy)

Value:

£

Describe circumstances:

Date:

(dd/mm/yyyy)

Value:

£

Describe circumstances:

How many years have you been continually insured at this property?

Years

Who is your current insurer?

When is cover required?

(dd/mm/yyyy)

What are you currently paying?

£

Any further information: