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First Name

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Last Name

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Email

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Telephone number

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Date of Birth

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First line of address

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Second line of address

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Postcode

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Town/City

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Occupation

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Employers Business

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Are you a resident of UK, Isle of Man, Channel Islands?

Yes No

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Have you or anyone living with you been refused insurance or had a policy cancelled?

Yes No

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If yes please provide details

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Is the address you wish to insure the same as the correspondence address?

Yes No

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If no please provide details

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Is the property you wish to insure your main home?

Yes No

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If no please provide details

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Does the property have a security alarm?

Audible – a Bell or Siren is activated: Monitored – when the bell of siren is activated , an alarm receiving centre is notified:

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Does the property have a fire alarm?

Mains wired alarm – smoke detectors linked to the electrical mains (not battery operated): Monitored – when smoke detected, an alarm receiving centre is notified:

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Does the property have CCTV?

Yes No

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Does the property have any water leak detection devices?

Yes No

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What is the total rebuild cost of the property?

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Do you have any Outbuildings?

Yes No

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What is the total rebuild value of your Outbuildings?

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What is the estimated total value of your Contents (excluding jewellery, watches, gemstones, precious metals, wine, fine arts including furniture and paintings, collections, stamps and coins, guns, cameras, musical instruments – these are covered under the Valuable Articles Section):

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Total Jewellery, Watches, Gemstones:

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Precious Metals (Silverware, tableware):

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Fine Art (Antique furniture, paintings, other bona fide works of art):

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Stamps Coins: these are currently as one can they be split:

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Guns:

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Cameras

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Wine

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Collectibles (rare unique or novel articles of personal interest):

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Musical Instruments:

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Furs

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Do you have a safe?

Yes No

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If yes what type of safe do you own? Grading or cash rating

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Home details

Buildings cover

Contents cover

Valuable articles

What is the estimated total value of the following: