HOUSEHOLD INSURANCE QUOTATION

Please provide the following details for a quotation for household/contents insurance.

Landlord / Tenant Name

Mr Miss Mrs Ms Surname

Landlord Tenant

Forenames

Landlord / Tenant Name

Mr Miss Mrs Ms Surname

Landlord Tenant

Forenames

Address of Property to be Insured (including Post Code)

Home Address of Landlord (inc. Post Code) if for Landlord Cover

Year Property Built

2000 + 1980 - 1999 1946 - 1979 1920 - 1945 1900 - 1919 1850 - 1899 Pre 1849

Number of Bedrooms

1 2 3 4 5

Age of Landlord / Tenant

Age of 2nd Applicant

Buildings Cover

Rebuilding Costs £

Contents Cover

Amount of Cover Required £5,000 £10,000 £15,000 £40,000

Increased Excess Option

£100 Standard Excess £250 Excess provides 15% discount £500 Excess provides 25% discount £1000 Excess provides 40% discount

Any other details that may effect this quote?

Contact Telephone Number

If we need to contact you?

Email Address Telephone No Fax No

If we contact you by phone please specify a suitable time Any None 9:00 9:15 9:30 9:45 10:00 10:15 10:30 10:45 11:00 11:15 11:30 11:45 12:00 12:15 12:30 12:45 13:00 13:15 13:30 13:45 14:00 14:15 14:30 14:45 15:00 15:15 15:30 15:45 16:00 16:15 16:30 16:45 17:00 17:15 17:30 17:45

Return Quote Via

Email Address Telephone No Fax No

Agent Name & No.

Keeleys F1570