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Name

Address

Postcode

How should we contact you?

Telephone Email Post Please select

Telephone Number

Email Address

Occupation

Age

How did you hear about R K Harrison?

A Friend Search Engine Press Advertisement Direct Mail Other Please select Professional Referral

Have you had any claims or
losses in the last 5 years?

Please select No Yes

If Yes, please give details, including the date, brief information of each incident and the cost of claim paid.

Is the home...?

Built of brick, stone or concrete and roofed with slates, tiles, metal, asphalt or concrete

Please select No Yes

In good repair and free from damage or defect of any kind

Please select No Yes

In an area normally free of flooding

Please select No Yes

Free from and in an area normally free of subsidence, ground heave, landslip or costal or river erosion

Please select No Yes

Free from precious underpinning or any remedial action of any type in connection with subsidence, ground heave, landslip or coastal or river erosion

Please select No Yes

Regularly occupied during the day

Please select No Yes

Regularly occupied during the night and not left unoccupied for more than 30 consecutive days

Please select No Yes

Occupied solely by the proposer and members of their family for private residential purposes

Please select No Yes

Fitted with 5 Lever Mortice Deadlocks to all external doors

Please select No Yes

Fitted with key operated window locks to all ground floor windows

Please select No Yes

Fitted with patio door locks

Please select No Yes

Fitted with an Alarm System

Please select No Yes

Fitted with a NACOSS approved Alarm System, with a  maintenance agreement

Please select No Yes

Details of any safes at the premises including make, model and age.

Details of the Cover Required/Sums Insured

Buildings (Min GBP250,000)

Main residence

Outbuildings

Fixtures and fittings

General contents (Min GBP100,000)

(excluding categories below but including clothing, baggage and personal possessions)

Fine Art (Single article limit GBP10,000)

Pictures/Books

Antique furniture

Porcelain/Brittle items

Gold, silver and plated items

Guns

Wine

Coins/Medals

Other fine art

Jewellery & Furs (Single article limit GBP10,000)

Unspecified jewellery under GBP5,000

Specified jewellery in excess of GBP5,000

Jewellery in a safe/Jewellery in a bank

Furs

Do you have a recent full valuation?

Please select No Yes

Name of valuer

Valuation dated

Current policy excess

Existing premium

Existing insurer