About You
To make sure you get the best deal, please complete your full name and not just initials

Title

Please Select Mr Mrs Miss Ms Dr Sir

First name(s)

Surname

Date of Birth

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31        January February March April May June July August September October November December       

Marital Status

Please Select Single Married Common Law Divorced Widowed Civil Partner

House Number

Street Name

Town

City

County

Post Code

Is this the property that you wish to insure?

Yes  No

Home Telephone No

Work Telephone No

Mobile Telephone No

Email Address

Preferred Method of Contact

Please Select Home Telephone Work Telephone Mobile Telephone Email Post

About The Property

Property Type

Please Select Bungalow - Detached Bungalow - Semi-Detached Chalet Bungalow - Detached Chalet Bungalow - Semi-detached Flat - Basement Flat - Ground Floor Flat - 1st Floor & Above House - Detached House - Semi-detached House - End-Terraced House - Linked-detached House - Mid-Terraced Maisonette

Approximate Year Built

Does the property have brick walls and a tiled roof?

Yes  No

Number of Bedrooms

Does the property have a burglar alarm?

Yes  No

Do you own or rent the property?

Please Select Own Rent

Number of adults at the property

Number of children aged 17 and under at the property

Is the property occupied during the day?

 Yes  No

Does anybody in the property smoke?

 Yes  No

About Your Cover

Cover Start Date

Cover Required

Have you, or anyone living with you made any claim under a home insurance policy within the last 5 years? (If yes, please complete the further details below)

Buildings Sum Insured

Contents Sum Insured

Legal
I/We understand that where the insurance requires supply of information relating to other persons who may be insured under the contract, that the information must be factual and accurate to enable correct assessment of risk by the insurer. I confirm that I have the consent of these individuals to supply their personal details to the insurer.
For the purposes of the Data Protection Act 1998 the data controller in relation to any personal data you supply is Cox Braithwaite Insurance Brokers.
I/we understand that the information I/we supply may be used by Cox Braithwaite Insurance Brokers to keep me informed by post, telephone, e-mail or other means about products and services which may be of interest to me. Please note that your information may also be used for these purposes after your policy has lapsed. If you do not wish your information to be used for marketing purposes, please tick this box
Your quotation will be based on the information you have provided above and this information will form the basis of your policy if you decide to buy, please check the information you have entered.