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Contact us at MSM
To receive a quotation for Home Buildings/Contents Insurance complete the missing sections below and resend your request. The required sections are highlighted in
red
.
To receive a Home Buildings / Contents Insurance quotation please complete this form.
First Applicant
Title:
Forename:
Surname:
Date of Birth:
/
/
Occupation:
Nature of business:
E-mail Address:
Second Applicant
Title:
Forename:
Surname:
Date of Birth:
/
/
Occupation:
Nature of business:
Applicant Contact Details
Applicant 1 Address:
Applicant 1 Telephone:
Applicant 2 Address:
Applicant 2 Telephone:
Total number of occupants of your home under 18 years old:
Details of other occupants apart from already those detailed above:
Name:
Age:
Occupation:
Relationship to the proposer:
Name:
Age:
Occupation:
Relationship to the proposer:
Name:
Age:
Occupation:
Relationship to the proposer:
Name:
Age:
Occupation:
Relationship to the proposer:
Declarations About You and Your Home
Is the home occupied by anyone other than the applicant(s) and their relatives or occupied in whole or part by tenants or paying guests:
Yes /
No
Have the applicant(s) or any person living in the home been convicted of or received a police caution for any criminal offence (other than motoring offences) or has a prosecution pending:
Yes /
No
Have the applicant(s) or any person living in the home ever had an insurance policy cancelled, been refused insurance or had special terms imposed:
Yes /
No
Is the home (including any garage or outbuildings) used for business purposes and/or there are callers to the property in connection with the applicant's business or profession:
Yes /
No
Are the applicant(s) or any person living in the home engaged in the entertainment business in any way:
Yes /
No
Have the applicant(s) or any person normally living in the home ever been declared bankrupt:
Yes /
No
Are the applicant(s) or any person living in the home smokers:
Yes /
No
Property Ownership
Is your home owned by you:
Yes /
No
If
YES
is your home owned:
On a mortgage/
Outright
If NO is the property rented:
Furnished /
Part-Furnished /
Unfurnished
Mortgage Lender (if applicable):
enter none if not applicable
Mortgage Roll / Account Number:
Address of Mortgage Lender:
Insured Address
If the insured address is different to the correspondence address enter this below. (If insured address has been lived at for less than 12 months please note previous address in the additional notes section)
How many bedrooms does your home have (including any room originally built to be used as a bedroom even if it is now used for other purposes):
Description of the home:
Please select
Detached House
Terraced Bungalow
Semi Detached House
Detached Bungalow
Semi Detached Bungalow
Terraced House
Flat
Maisonette
Studio
Other
Year home was built:
Does the home have a non standard construction (i.e. the external walls are not built of brick, stone or concrete, or less than 80% of the home is not roofed with slate, clay or concrete tiles, concrete or metal):
Yes /
No
Is the home built solely of stone:
Yes /
No
Is there any asbestos in the property:
Yes /
No
Is the home (including garage) in a bad state of repair or is not maintained:
Yes /
No
Is the home not self-contained (i.e. it does not have a separate and private entrance under your sole control:
Yes /
No
The home will not be lived on from commencement date of this insurance or completion of purchase:
Yes /
No
The home (including garage) is in a locality where there is evidence (or a history) of subsidence, heave, landslip or flooding:
Yes /
No
The home (including garage and outbuildings) has sustained previous damage by subsidence, heave or landslip, and/or has it been underpinned or provided with other means of structural support:
Yes /
No
The home is not my main residence, or is a holiday (or weekend) home or is likely to be left unoccupied for more than 30 days at a time:
Yes /
No
Is the home (including garage) situated less than ¼ mile (400m) from the nearest river, watercourse or sea:
Yes /
No
Is the home (including garage) currently undergoing renovation or construction work:
Yes /
No
Is the home a listed building:
Yes /
No
Is the home normally unoccupied throughout the day:
Yes /
No
Is the home normally unoccupied outside normal working hours:
Yes /
No
Is the home not fitted with at least one smoke detector:
Yes /
No
The home does not have gas central heating system:
Yes /
No
Buildings Cover
Buildings cover required:
Yes /
No
If
yes
Buildings Sum Insured:
£
Cover:
Please select the cover required
Standard Cover
Standard Cover with Accidental Damage
Buildings Excess:
£
Select
£50
£100
£150
£200
£250
£300
£350
£400
£450
£500
£1000
Date of Purchase:
Select
January
February
March
April
May
June
July
August
September
October
November
December
Year of Purchase:
Date of Occupancy:
Select
January
February
March
April
May
June
July
August
September
October
November
December
Year of Occupancy:
Buildings Years Claims FREE:
Please select
0 year
1 year
2 years
3 years
4 years
5 years
6+ years
Contents Cover
Contents cover required:
Yes /
No
If
yes
Contents Sum Insured:
£
Cover:
Please select the cover required
Standard Cover
Standard Cover with Accidental Damage
Contents Excess:
£
Select
£50
£100
£150
£200
£250
£300
£350
£400
£450
£500
£1000
Contents Years Claims FREE:
Please select
0 year
1 year
2 years
3 years
4 years
5 years
6+ years
Amount of Valuables included with the Contents Sum Insured above:
£
Please state any valuables (gold, silver or other precious metals, jewellery, furs, pictures or other works of art, collections of stamps or coins) which exceed £1000 in value.
Do not include any article insured separately under Personal Possessions.
Is the final exit door secured by a deadlock, all other external doors either secured by a deadlock or fitted top and bottom with key operated security bolts and all accessible windows fitted with key operated window locks:
Yes /
No
Is your home protected by an intruder alarm system installed and maintained by a NACOSS (National Approval Council for Security Systems) recognised firm:
Yes /
No
If yes name the burglar alarm installation company:
If yes name the burglar alarm maintenance company:
Are you a member of a police approved Neighbourhood Watch Scheme:
Yes /
No
Are there any other protections installed at the insured property:
Yes /
No
If
yes
please provide additional details:
Personal Possessions Cover
Personal Possessions cover required:
Yes /
No
Unspecified Personal Possessions Sum Insured:
£
Details of Specified Personal Possessions:
Details of Pedal Cycles and Accessories:
Claims and Cover Information
Has applicant 1 ever held Household Insurance before:
Yes /
No
If
YES
please state the name and policy number of your previous building insurer and the name and policy number of your previous contents insurer:
Give details of any previous losses or claims on your household / contents insurance:
When would you like this cover to commence (please note policies can NOT be back dated):
Date insurance to start from:
/
/
for 12 months
Optional Extra Cover
Family Legal Protection cover:
Yes /
No
Garden cover:
Yes /
No
Additional Notes
MSM Insurance
, P.O. Box 5526, Takeley, Bishop's Stortford, Herts CM22 6PZ
Telephone:
01279 870535
Fax:
01279 870636
E-mail:
info@msminsurance.co.uk
