Household Form

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Proposers Details:

Please note that you will be required to do everything reasonable to ensure that you provide accurate and complete answers to all questions asked.

Gender *

Your Correspondence Address:

Are you a smoker?*

Do you require Joint Proposer?*

Do you have any non-motor convictions*

Are you a first time buyer?*

Have you ever had a proposal declined or special terms imposed?*

Have you been bankcrupt or had CCJ's etc?*



Joint Proposer

If you do not have a joint proposer, please proceed to premises details

Gender

Are you a smoker?

Risk Address

Are you a smoker?



Premises Details

Main Residence*

Has your home been extended, other than for a conservatory, which has resulted in more than 10% increase in the original floor area?*

Is your home used for business purpose?*

Is this on a manual or clerical basis?

Is the property together with the surrounding area free from signs of damage (e.g. cracking or bulging walls) and free from subsidence or underpinning?*

Free from flooding?*

Are there any trees or shrubs within 7-seven Metres (22-twenty two feet) of the property, which are, more than 5-five Metres (16-sixteen feet) tall?*

Is the property within 400m of a riverbank, lake, seafront, reservoir, quarry or other excavation?*

Is it in good repair and well maintained:*

Is this home occupied solely by you and your family as a permanent residence?*

Is the property self-contained with a separate lockable entrance under your sole control? *

Occupied Daily*

Occupied Nightly*



Security Details

Alarm Installed*

Approved Locks Fitted (Key operated window locks & 5 lever mortise dead locks to front & rear doors):*

Exterior Security Lighting*

Are you a member of the Neighbourhood Watch:*

Smoke Detectors*

Safe Installed*

Covers Required

Buldings Cover

Accidental Damage*



Contents In The Home

Accidental Damage*



Personal Possessions Away From The Home

If you dont require this then please go to Claim Details

Unspecified Items with an individual value of less than £1,500



Do you require?

Personal Money

Credit Card

Frozen Food

Specified Items with an individual value of £1,500 or more



Claim Details

Have you had any household claims in the past five years or any claims at any time in respect of subsidence, heave, or landslip? If so please advise here:*

Under Contents?

Under Buildings?

Under Contents & Buildings? [radio UnderContents&Buildings use_label_element default:1 "Yes" "No"]

Did it happen at the current address?

Are there any additional claims? If No, please proceed to Submit*

Additional Claim Details

Under Contents?

Under Buildings?

Under Contents & Buildings? [radio AdditionalContents&Buildings use_label_element default:1 "Yes" "No"]

Did it happen at the current address? YesNo

Authorised and Regulated by the Financial Conduct Authority
Crest Consort and Crest Class are trading names of Crest Insurance Consultants ltd
Registration number 306380

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