Buildings & Contents Enquiry Form

Please complete the form below and click 'submit':

Name
Address
Postcode
How should we contact you?	Please select Email Telephone Post
Telephone Number
Email Address
Occupation
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 1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023
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.
Type of property	Please select Detached House Semi Detached House Terraced House Bungalow Semi Detached Bungalow Purpose Built Flat Converted Flat Other
Year Built
Number of Bedrooms	Please select 1 2 3 4 5 6 7 8 9 10+
Is the property rented?	Please select No Yes
Is the home...?
Built of brick, stone or concrete and roofed with slates, tiles, metal, asphalt or concrete
In good repair, free from damage or defect of any kind and in an area normally free from flooding, free from and in an area normally free from subsidence, ground heave, landslip or costal or river erosion
Free from previous underpinning or any remedial action of any type in connection with subsidence, ground heave, landslip or coastal or river erosion
Regularly occupied during the day
Regularly occupied during the night and not left unoccupied for more than 30 consecutive days
Occupied solely by the proposer and members of their family for private residential purposes
If not, please give details:
Fitted with 5 Lever Mortice Deadlocks to all external doors	Please select No Yes
Fitted with key operated window and patio door locks to all ground floor windows and patio doors	Please select No Yes
Fitted with a NACOSS or SSAIB approved Burglar Alarm System, with a maintenance agreement	Please select None Audible Only Digicom RedCare
Details of the Cover Required/Sums Insured
Buildings
Estimated Rebuilding Cost
Cover	Please select Not Required Accidental Damage Standard
General Contents
Sum Insured
Cover	Please select Not Required Accidental Damage Standard
Personal Possessions (Away from the home)
Unspecified Personal Possessions & Jewellery
(Single Item Limit £1,000)
Items over £1,000: Description	Value
Additional Options (Check box if required)
Pedal Cycles
Money
Credit Cards
Freezer Contents
Legal Expenses
Please provide any other information that might affect the underwriter's assessment of this risk.

    

The details you have provided will be used by Chubb Insurance Brokers to send you the information you have requested. We may wish to contact you by post, email or telephone. By providing your contact details or when completing an online quotation you are consenting to be contacted about that quotation. We may also wish to use your details to let you know about other products and services offered by Chubb Insurance Brokers Ltd, full details available on request, and carefully selected third parties. By providing your contact details you are consenting to be contacted for such marketing purposes.