CITYMAIN INSURANCE

BUILDINGS, CONTENTS & PERSONAL EFFECTS

UK Residents Only
We regret that this does not include N. Ireland.

For the best Home and Contents Insurance Premiums complete the Application Form

and submit it to US.

Please supply your details:

        Mr.  Mrs.  Miss.  Ms. Other        

       Surname         First Names     D.O.B

        Occupation:        Are you Retired? YESNO

        Day Time Telephone Number:    Extension if applicable

        The Address of the Property to be Insured: 

                                                        Town          

                                                        County        

        The Post Code of the Property to be Insured:

        The approximate year the Property was built:    Is the Property permanently occupied? YesNo

        Do you have an Alarm? Yes No  

        If Yes, was it installed by NACOSS approved installer and is it regularly maintained? Yes No

        Do You have a Safe?  Yes No

        Previous Insurers of this Property whilst in your ownership, if None give reason

        Insurance Required From

       Please Specify the Amounts you required to be insured below:

Buildings: Sum Insured Contents: Sum Insured Personal Possessions

£

£

£

Do You Require Accidental Damage to Buildings?  YES    NO

Would you like to reduce the excess on Contents from £100 to £50 ?  YES  NO

Please list Items, Pairs or Sets covered under Section B & C(Contents & Fine Arts etc) with a value of more than £15,000

Please list Items, Pairs or Sets covered under Section D(Personal Effects) with a value of more than £5,000

Would you like to include Family Legal Protection and Insured Property Assistance
For an Additional Premium   YES  NO

Property Construction & Security

I the proposer confirm the following:

The Property is of standard construction, built of brick, stone or concrete and is in a good state of repair.

The property is in an area free from flooding and normally free from subsidence, heave, landslide or
coastal river erosion. The Property is free from signs of damage due to subsidence, heave or landslide
(such as external or internal cracks). The Property has not been monitored (and is not being monitored),
for subsidence, heave or landslide. The Property has not been the subject of a survey which mentions
settlement or movement of buildings. (If you cannot confirm this please provide details below).

All external doors are fitted with 5 lever mortice deadlocks and all ground floor windows, fanlights
skylights and patio doors have key operated locks.

Neither I, or any member of my family living with me has been refused Insurance or had any special
terms and conditions imposed, been convicted of, or has prosecutions pending for any criminal
acts (other than motor offences).

Neither I, or any member of my family living with me has made a claim within the last 5 years
or had a claim pending against them.

If you are unable to confirm any of the above statements please provide details :-

       DISCLOSURE

        You are reminded of the need to disclose any facts that are likely to affect acceptance or assessment of this
        Insurance to advise Insurers of any alteration of the risk after commencement of this Insurance. Where
        there is any doubt whether facts would be considered material those facts should be disclosed.

        Declaration

        I/We declare that the Information given in this Application, is to the best of my/our knowledge and belief, correct
        and complete and that I/We have read the note headed Disclosure. I/We understand that the submission of this
        Application does not bind me/us to complete the Insurance and that the Insurance will not be in force until this
        Application has been accepted by Insurers except to the extent of any official Cover Note or Schedule that may
        have been Issued.

        Please Enter your Email Address   and today's date

                               

Quotation is subject to satisfactorily completed application and compliance with any risk requirements (if applicable).
Insurers share information with each other to prevent fraudulent claims and for underwriting purposes via the Claims
Underwriting Exchange Register, operated by Insurance Database Services Ltd. A list of all participants is available
on request and in dealing with you application we may search this register. In the event of a claim the information you
supply on this form together with other information relating to the claim, will be provided to participants

Please NOTE that by submitting this Form we consider it to be electronically signed.

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