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Household Insurance Form with £50 off
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
[Please select]
Mr
Mrs
Miss
Ms
First Name
Second/Middle
Surname
Date of Birth
Sex
[Please select]
Male
Female
Name or number of your home
Postcode
*
How do you want us to contact you?
[Please select]
Email
Telephone
E-mail Address
Preferred time of call
[Please select]
Morning
Afternoon
Preferred contact number (including code)
How did you hear about us?
[Please select]
Existing client
Past client
Recommendation
Radio advert
Press advert
Yellow pages
This is Jersey
Type of property
[Please select]
Detached
Semi-Detached
Terrace
Detached bungalow
Self contained flat
Room or bedsit
other flat
Other
Number of bedrooms
[Please select]
1
2
3
4
5
Is the building of standard construction
[Please select]
Yes
No
(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
[Please select]
Pre 1920
1920-1945
1946-1979
1980-1989
1990-present
Ownership of the property
[Please select]
Tenant
Owner/Occupier
Is the property occupied during the day
[Please select]
Yes
No
How long have you held household insurance
[Please select]
Never/Less than 1 year
Over 1 year
Over 2 years
Over 3 years
Over 4 years
Over 5 years
How many claims have you made in the last 3 years
[Please select]
none
1
2
3
4
5 or more
Do you want building insurance
[Please select]
Yes
No
If yes, enter your sum insured
Do you want Accidental Damage cover
[Please select]
Yes
No
Do you want contents insurance
[Please select]
Yes
No
If yes, enter your sum insured
Do you want Accidental Damage cover
[Please select]
Yes
No
Do you want to insure personal possessions away from your home
[Please select]
Yes
No
If yes, select the appropriate sum insured
[Please select]
0
5
000
10
000
over 10
000
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.
Channel Islands
Jersey
Guernsey
Alderney
United Kingdom
Southampton
Isle of Man
Douglas
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