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Let Properties Quote
Let Properties Quote Form
1
Client Details
2
Property details
3
Heating
4
Sums Insured
5
Security
6
Claims & Previous History
Are you an agent of County Insurance Services?
*
Yes
No
Agent Name:
*
Agent Contact Number:
*
Agent Email:
*
Full Name including title:
*
Date of Birth:
*
Date Format: DD slash MM slash YYYY
Occupation including nature of business:
*
Would you like to apply for a joint policy?
*
Yes
No
Full Name including title:
*
Date of Birth:
*
Date Format: DD slash MM slash YYYY
Occupation including nature of business:
*
Client telephone number:
*
Client email address:
*
Are you a permanent resident In the UK?
*
Yes
No
If no, please provide details:
*
Correspondence address (including post code):
*
Street Address
Address Line 2
City
ZIP / Postal Code
Country
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Full Address (including post code) of property to be Insured:
*
Street Address
Address Line 2
City
ZIP / Postal Code
Country
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Has the property any history of subsidence, heave landslip or flooding?
*
Yes
No
If Yes, please provide details (including date of incident):
*
Is the property in a good state of repair?
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Yes
No
No, please provide details:
*
Are you planning any building work or renovation?
*
Yes
No
Yes, please provide details:
*
Occupancy (Please select):
*
Main Residence
Professional Let
Holiday Let
Holiday Home
Unoccupied
If unoccupied please state reason for unoccupancy:
*
How long is it anticipated the property will remain unoccupied:
*
Is working from home cover required?
*
Yes
No
If Yes, please provide details of business activities:
*
Property Type (please select):
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Detached
Semi Detached
Mid-Terrace
End-Terrace
Maisonette
Building construction:
*
Roof construction:
*
Year of construction:
*
Number of bedrooms:
*
Is the property Listed?
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Yes
No
If Yes, what grade?
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Does the property have smoke detectors on each level?
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Yes
No
Please state all forms of heating in the property:
*
Buildings
The buildings sum insured should represent the full cost of reinstatement of the property (including the cost of professional fees and site clearance), any garages, greenhouses and other outbuildings, swimming pools, walls, gates and fences. If the property is listed then VAT will also need to be included. Outbuildings are covered up to £15,000 automatically; any outbuildings exceeding this in reinstatement/rebuild value must be specified.
Main Building (£):
*
Outbuilding 1 (Optional) (£):
Outbuilding 2 (Optional) (£):
Outbuilding 3 (Optional) (£):
Outbuildings total (£):
Total Buildings sum insured (£):
*
Is accidental damage cover required?
*
Yes
No
Is a voluntary excess required? Please select:
£100
£250
£500
£1000
*Please note that there is a compulsory policy excess of £100 on main residence and £250 on all others. The voluntary excess will apply in addition to the compulsory excess.
Please provide the name and address of any party whose interests are to be noted e.g. mortgage lender:
Mortgage reference no:
Contents
The contents sum insured should represent the full cost of replacing (as new) the entire contents within the property, including valuables and high risk items. Contents are household goods including furniture, furnishings (such as carpets and curtains) and all items not fixed to the property.
General Contents (£):
*
Outdoor Items (£):
Redundant Jewellery never worn or taken out of the home (£):
Fine Art & Antiques (£):
Total Contents (£):
*
Is accidental damage cover required?
*
Yes
No
Is a voluntary excess required? Please select:
£100
£250
£500
£1000
*Please note that there is a compulsory policy excess of £100 on main residence and £250 on all others. The voluntary excess will apply in addition to the compulsory excess.
Personal Possessions (Optional)
Items you may have on your person when out of the home such as jewellery, laptop computers, luggage whilst on holiday. Single article limit is £2,500 unless specified.
Unspecified items total (no one item worth more than £2,500):
Specified item (with individual value in excess of £2,500):
Specified item description:
Specified item 2 (with individual value in excess of £2,500):
Specified item 2 description:
Specified item 3 (with individual value in excess of £2,500):
Specified item 3 description:
Specified item 4 (with individual value in excess of £2,500):
Specified item 4 description:
Specified item 5 (with individual value in excess of £2,500):
Specified item 5 description:
Pedal Cycles (Optional)
Pedal cycles may be included up to a maximum of £5,000. Any pedal cycles over the value of £500 must be specified.
Number of unspecified cycles:
Number of unspecified cycles:
Specified cycle description:
Specified cycle value (£):
Specified cycle 2 description:
Specified cycle 2 value (£):
Specified cycle 3 description:
Specified cycle 3 value (£):
Specified cycle 4 description:
Specified cycle value 4 (£):
Is the property fitted with 5 lever mortice deadlocks & key operated window locks?
*
Yes
No
If No, please provide details of alternative locks in place:
*
Is there a burglar alarm installed at the property?
*
Yes
No
Yes, please confirm the type:
*
Is the alarm covered by an annual maintenance agreement?
*
Yes
No
Is there a safe in the property?
*
Yes
No
If Yes, please confirm make, model & rating
*
Any claims in the past 5 years?
*
Yes
No
Claim details, including circumstances, insurers & address of property where the incident occurred:
*
Date of claim:
*
Date Format: DD slash MM slash YYYY
Value of claim:
*
Would you like to add another claim?
*
Yes
No
Claim details, including circumstances, insurers & address of property where the incident occurred:
*
Date of claim:
*
Date Format: DD slash MM slash YYYY
Value of claim:
*
Would you like to add another claim?
*
Yes
No
Claim details, including circumstances, insurers & address of property where the incident occurred:
*
Date of claim:
*
Date Format: DD slash MM slash YYYY
Value of claim:
*
Have you held insurance continuously for the Past 5 years?
*
Yes
No
If no, provide details:
*
How many years no claims discount do you currently have?
*
Are you a first-time buyer?
*
Yes
No
Have You or any person residing with you, ever been declared bankrupt?
*
Yes
No
Have you or any person residing with you ever been convicted of ANY offence, other than motoring offenses, or are there any penalty convictions?
*
Yes
No
You are not required to disclose convictions regarded as ‘spent’ by virtue of the Rehabilitation of Offenders Act 1974. If you have stated Yes to the above please give full details below
*
Please use the space below for any further details.
Current Insurer:
*
Renewal Date:
*
Date Format: DD slash MM slash YYYY
Renewal Premium (£):
*
Target Premium (£):
*
Declaration
*
I/We confirm that this form has been completed to the best of our knowledge
Date
*
Date Format: DD slash MM slash YYYY
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