Broad Insure | Car Quote Form

How did you hear about us?

Name:

Number:

Title *

Your First Name *

Your Middle Name (If any)

Your Surname *

Your Date of Birth *

Marital Status *

Employment Status *

If Employed/Self Employed, What is your occupation: *

If Employed/Self Employed, What is your business: *

Were you born in the UK

Yes

No

If No, when did you last become a UK resident?

Email:

Contact Number:*

Property Address:*

Type of Property

Estimated year property built:

Number of living rooms:

Number of kitchens:

Number of bathrooms:

Number of bedrooms:

Are there any trees taller than 10m within 5m of the property:

Yes

No

Approximate % of flat roof:

Do you own this property:

Who lives in the property:

How many years have they lived at the property:

How many adults live in the property:

How many children under the age of 18 live in the property:

When is the property usually occupied:

For how many days in a row is the property left empty (e.g. holidays):

Does anybody in the property smoke:

Yes

No

Is the property ever used for business use:

Yes

No

Does the property have an alarm:

DWhat lock is fitted to your main door

What other lock is fitted to any other external doors:

Do all ground floor windows have key operated locks:

Yes

No

How many working smoke alarms are there in the property:

Rebuild value of the property:

Would you like accidental damage cover for buildings:

Yes

No

How many years NCB do you have buildings insurance:

Contents value of the property: (including fixtures, furniture, utensils)

Any specific items worth over £1000:

Yes

No

Would you like cover away from home:

Yes

No

Would you like accidental damage cover for contents:

Yes

No

How many years NCB do you have content insurance:

In the past 5 years, have you or anyone living at the property made any home insurance claims or suffered any losses or damage, whether insured or not:

Yes

No

When would you like the cover to start:

Is built with brick walls?

Is more than 400 meters away from water

Has a roof made of slate or tile

Is not for sale

Has never shown signs of heave, landslip or subsidence

Is your main residence

Has not had underpinning or structural support

Is not currently undergoing building work

Has never suffered from flooding

Has no significant cracks on the external wall

Do you agree with the above assumptions?

Yes

No

*

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Personal Info

Assumptions bellow are correct: (input tick boxes what would be pre-ticked)

The Property