PFM Dental

HOME INSURANCE QUOTATION REQUEST FORM

Please complete the form to enable us to provide you with a quotation for your home insurance.

Title:	Title:
Name:	Partners Name:
Date of Birth: Smoker:	Date of Birth: Smoker:
Contact No.:	Contact No.:

Correspondence Address:	Property to be insured, if different from correspondence:
Postcode:	Postcode:

Residents: Please give details of all other persons aged over 18 residing at the insured property
Name	Age	Occupation	Relationship


Please enter here the number of minors (those aged under 18) residing at the

When would you like your insurance to commence?
Have you an existing Buildings and or contents insurance policy?
What is your existing premium?	£

BUILDING INSURANCE
Value of property: £	Rebuild cost: £
Do you require Accidental Damage on your Buildings Insurance?
Mortgage Lender:	Ref:
Property build (year):	No. of bedrooms:

Type of property:

If applicable, which floor is it on? Is it self contained?

What are the exterior walls made of?

What is the roof made of?

Is the property near river, watercourse or the sea?	If so, how close?
Has there been any flooding in the area?	If so, how close?
Has there been any subsidence or signs of subsidence?	If so, how close?
Is the property undergoing any renovation or construction work?	If so, please give details:
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 accessible windows fitted with key operated window locks?
Is your home protected by an intruder alarm system installed and maintained by a NACOSS (National Approval Council for Security Systems) recognised firm?
Are you a member of a police approved neighbourhood watch scheme?

CONTENTS INSURANCE
Contents sum to be insured? £
Do you require Accidental Damage on your Contents Insurance?
Is personal possession (non-specified) insurance required?	If so, for how much? £
Is garden cover required?	If so, for how much? £
Do you have pedal cycles to insure?	If so, for how much? £
Are there any personal possessions (specified) worth over £1,000?
Details of personal possessions worth over £1,000. Please include individual value of items:

CLAIM HISTORY
Are you a first time buyer?
Do you have any no claims discount on your buildings insurance?	If so, how many years?
Do you have any no claims discount on your contents insurance?	If so, how many years?

Have you had any claims on your Buildings and Contents Insurance in the last 6 years?
If applicable, details of the claims. Please include date, reason, and value of each claim:

DECLARATIONS ABOUT YOU AND YOUR HOME
Please read the following statements carefully and tick only those which apply
The home is occupied by someone other than the applicant(s) and their relative/s, or occupied in whole or part by tenants or paying guests.
The applicant(s) or someone living in the home has been convicted of, or received a police caution for any criminal offence (other than motoring offences) or has a prosecution pending.
The applicant(s) or someone living in the home has previously had an insurance policy cancelled, been refused insurance or had special terms imposed.
The home is not my main residence, or is a holiday (or weekend) home, or is likely to be left unoccupied more than 30 days at a time.
The home (including any garages or outbuildings) is used for business purposes and/or there are callers to the property in connection with the applicant's business or profession.

CLIENT(S) DECLARATION

I hereby authorise and request Practice Financial Management Ltd to obtain a quotation for home insurance based on the information that I have provided.

I confirm that the above information is true and correct to the best of my knowledge and that all material facts have been disclosed. I understand that if this is not the case that the insurance policy may be invalid. I also realise that if there are any changes to my circumstances, that I must inform Practice Financial Management Ltd or your selected insurer.

I have read, and agree to, the above declaration