Household Insurance Quotation Form - DOC by sju15724


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									Household Insurance
Quotation Form
Reference: IntFree
Return by 31st October 2009 and you will
be eligible for the offer until
31st August 2010
Policyholder details                                       Joint Insured details (if applicable)
Name:                                                      Name:
Date of birth:                                             Date of birth:
Occupation:                                                Occupation:
Correspondence                                             Insured
address:                                                   Property
                                                           (If different)

Telephone number:
Email address:
When is the best time
for us to contact you?
                                                            Buildings            Contents          Combined
Do your existing policies include Accidental
Damage cover?
What are your current renewal dates?
What are your current household premiums?
Who is your existing insurer for each of the above?
In what year was your home built?
Please state the type of building
(i.e Semi-detached house, bungalow, flat)
Please state number of bedrooms in the property
Are any building works currently in progress? If yes please give full details below

Please answer YES or NO to indicate if the property to be insured is:                      YES        NO
Of standard construction and in good state of repair?
Used for business purposes or open to the public?
Occupied as your permanent residence?
Left unattended for more than 30 consecutive days?
Free from subsidence, ground heave or landslip?
In an area which is free from flooding?
Fitted with 5 lever mortice deadlocks?
Fitted with a burglar alarm?
Smoke detectors on all levels?
Smoke detectors on partial levels only?
Have you made any claims in the last 5 years?
Are there any trees within 7 metres of the property which are taller than the house?
Is there a safe installed?
If you have answered YES or NO in any of the shaded boxes in respect of the above questions about the
property please provide full details in the additional information box below.
Additional information
 Please indicate the sums to be insured as follows:
 Buildings                                                                                        £
 General Contents (total in the home)                                                             £
 Computer Equipment                                                                               £
 Personal effects (total to be covered outside the home)                                          £
 Pedal cycles                                                                                     £
 Jewellery (total to be covered inside the home)                                                  £
 Jewellery (total to be covered outside the home)                                                 £
 Furs                                                                                             £
 Frozen Food Cover                                                                                £
 If you require cover for frozen foods please provide the age of your freezer
 Please answer YES or NO to the following additional questions:                                                      YES          NO

 Do you require accidental damage cover for your buildings?

 Do you require accidental damage cover for your contents?

 Is your home or part of used for business purposes?
 Does the total amount of all valuables* amount to £5,000 or 20% of the contents sum

 Does any single item of valuables* (including pairs or sets) exceed £1,500?
 *Definition of valuables - This refers to jewellery, furs, gold, silver, gold and silver plated articles and pictures.
 If you have answered YES to either of the above questions in either one of the shaded boxes then please
 provide additional details in the Additional Information box below.
 Additional information

                         Cover is subject to underwriters acceptance, terms and conditions.

Please return your completed quotation form by email by fax 01603 625 230 or post: Diabetes UK
Insurance Services, Grosvenor House, 112-114 Prince of Wales Road,
Norwich NR1 1NS.

Diabetes UK Insurance Services is a trading name of Heath Lambert Limited, which is authorised and regulated by the Financial Services
Authority. Registered Office: 133 Houndsditch, London EC3A 7AH. Registered Number: 1199129 England and Wales.

Data Protection Act 1998
Both parties shall comply at all times with the Data Protection Act 1998 (DPA) and any regulations made under the DPA and
in particular with the data protection principles set out in the DPA and with all relevant guidelines and guidance notes issued
from time to time by the Information Commissioner, as applicable to each of those parties. Where personal data is supplied or
disclosed by one party to the other, the other party will: a) ensure that such personal data is only used for the purposes for
which appropriate consent has been given by the data subject; and b) notify the disclosing party of any request it receives
from data subjects for subject access or changes to such personal data under the DPA or any correspondence with the
Information Commissioner in relation to such personal data.

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