SECTION 1 - FIRST PROPOSER                                                      

Title

Mr Ms Mrs Dr Fr

First Name

Last Name

Date of Birth

Occupation

Employment Status

Employed Self-Employed Home-Keeper Unemployed Retired

If Company Director, Manager or similar, state nature of business

E:Mail address

Postal address

If different from above - Risk address

Contact Telephone Numbers

(Area Code) (Day) (Area Code) (Evening) (Area Code) (Home) (Area Code) (Work)

Date Cover Required From:

If your Buildings have an Interested Party (Building Society, Bank etc) please state their name and address

(Name) (Address)

Date Cover Required To:

SECTION 2 - SECOND PROPOSER:                                                   

Title

Mr Ms Mrs Dr Fr

First Name

Last Name

Date of Birth

Occupation

Employment Status

Employed Self-Employed Home-Keeper Unemployed Retired

If Company Director, Manager or similar, state nature of business

If your Buildings have an Interested Party (Building Society, Bank etc) please state their name and address

(Name) (Address)

SECTION 3 - HOUSE DETAILS - Please tick Yes or No as appropriate                                          

1:   Type of House

Detached Semi-Detached Terraced Flat Apartment Holiday Home Guest House Bed and Breakfast Bungalow

2:  Please state Number of Bedrooms

* A Bedroom means a room used as or originally designed as a bedroom, even if it is currently used for a different purpose.

1 2 3 4 5 6 7 8 9 10 Over 10

3:  Please state Number of Storeys

1 2 3 4 Over 4

4:  Year Built

5:  If Flat or Apartment situated on which storey

6:  Is the dwelling your permanent residence and occupied solely by you and members of your family

Yes No

7:  Is the premises in good repair

Yes No

8:  Is the dwelling built of brick, stone or concrete and roofed with slates, tiles or concrete

Yes No

9:  If any part of the dwelling is roofed with mineral felt on timber, please state

Yes No

(a) Percentage in relation to the total roof area

(b) Approximate Age

10:  Is any part of the premises used for business or professional purposes

Yes No

11:  Is any part of the premises let or sublet

Yes No

If ‘Yes’ to how many tenants

12:  Do your provide accommodation for paying guests

Yes No

If ‘Yes’ how many

13:  Is the dwelling left unoccupied regularly during the day or night

Yes No

14:  Is the dwelling left unoccupied for more than 30 consecutive days in any one period of insurance

Yes No

15:  Is the premises partially exposed to damage by Storm, Flooding, Subsidence or Landslip

Yes No

If the answer to any of the above questions numbers 10-15 is ‘Yes’, please provide details

SECTION 4:  SECURITY DETAILS  -   Please tick Yes or No as appropriate

1:  Are all External Doors fitted with a five lever mortice deadlock and/or key operated rim deadlocking nightlatch.

Yes No

2:  Are Sliding Patio Doors fitted with a key operated security lock

Yes No

3: Are all Accessible Windows fitted with a key operated security lock

Yes No

4:  Is the dwelling fitted with two or more Smoke Alarms

Yes No

5:  Is an Intruder Alarm installed

Yes No

If ‘Yes’ please state Manufacturers name

5a:  Does it conform to the IS199 standard and protect all external doors and accessible windows

Yes No

5b:  Is the alarm maintained in efficient working order

Yes No

5c:  Is the alarm connected to a central monitoring station

Yes No

6:  Are you a member of Neighbourhood Watch or Community Alert

Yes No

7:  Do you or any member of the household smoke

Yes No

SECTION 5 - CLAIMS - Please tick Yes or No as appropriate

1:  Have you, or any member of your household made a claim for any loss, damage, or liability under a Home or Household Insurance Policy in the past 3 years.

Yes No

If you have answered ‘Yes’ to the above, please give details

2:  Has the premises to your knowledge, ever suffered loss and/or damage as a result of Flood or Subsidence

Yes No

If you have answered ‘Yes’ to the above, please give details

SECTION 6 - COVER DETAILS - BUILDING & CONTENTS

1:  What is the full rebuilding cost of your home

2:  What is the full replacement cost of your contents

3:  Is Personal Accident cover required

Yes No

4:  Unspecified Personal Possessions - Sum Insured

5:  Specified Items ie. with a value over Euro1,000
             Please list items and individual values

SECTION 7 - GENERAL - Please tick Yes or No as appropriate

1:  Have you in the past 5 years been insured for the risks being proposed.

Yes No

1a:  If you have answered ‘Yes’ to the above, please provide the name of the company

2: Has any member of your household been cautioned for, convicted of, or charged but not yet tried for any criminal offense other than a motoring offense

Yes No

2a;  If you have answered ‘Yes’ to the above, please provide details.

3:  In connection with the Insurance Cover you now require, have you or any of your household:

Had any insurance declined, made subject to special terms and conditions, or been requested to take additional precautions

Yes No

3a)  If you have answered ‘Yes’ to the above, please provide details.

4.   Suffered any losses, or been involved in any accident, whether insured or not, in the last five years

Yes No

4a:  If you have answered ‘Yes’ to the above, please provide details.