Household Insurance Form

Please take a moment to fill out this form and one of our brokers will contact you shortly to offer you a quotation or discuss your requirements further
Title
First Name
Second/Middle
Surname
Date of Birth
Sex
Name or number of your home
Postcode	*
How do you want us to contact you?
E-mail Address
Preferred contact number (including code)
Preferred time of call
How did you hear about us
Type of property
Number of bedrooms
Is the building of standard construction
(Standard construction means built of brick, stone, concrete block and roofed mainly with slate or tiles with no more than 20% flat/felt/ruberoid roofing)
When was the property built
Ownership of the property
Is the property occupied during the day
How long have you held household insurance
How many claims have you made in the last 3 years
Do you want building insurance
If yes, enter your sum insured
Do you want Accidental Damage cover
Do you want contents insurance
If yes, enter your sum insured
Do you want Accidental Damage cover
Do you want to insure personal possessions away from your home
If yes, select the appropriate sum insured

If you have been asked to quote a reference, please enter it here
Privacy and Data Protection
The Rossborough Group holds your details in accordance with relevant Data Protection Law in the UK, Isle of Man and Channel Islands.
Some or all of the information you supply to us in connection with your insurance proposal will be held on computer and may be passed to insurance companies for underwriting and claims purposes. In addition, we may use some of the information to advise you of other products and services offered by the Rossborough Group.
If you do not wish to receive such details please contact our Compliance Officer.

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Household Insurance Form

Privacy and Data Protection