Assetsure Limited  (Firm Registration No. 466550) is authorised and regulated by the Financial Services Authority .   Privacy - Assetsure are registered under the Data Protection Act 1988 (Registration number Z9841506). We do not store any personal information about individuals who visit this site except where they provide contact information.
	Property to be Insured
	Location of Property		Please Select UK Spain Portugal France Malta Gibraltar
	Address (inc zip/ postcode)
	Property Type		Please Select Apartment or Flat Attic Room Ground Floor Flat Terraced House Detached
	Local Surroundings		Please Select Urbanisation Other
	Distance From Sea		Please Choose More than 300m Less than 300m
	How is the Property Occupied		Please Choose Main Residence Our Holiday Home/ Second Home Our Holiday Home/Part Rented Rented on a Long Contract (over 12 months) Short term Holiday Rental
	Security		Grills or Bars on Windows
			Solid Timber Doors
			Direct Line Alarm
			Armoured Doors
			Laminated Glass Windows
			Other
	If 'Other', please Specify
	Building Sum Insured (Pounds Stirling)
	Contents Sum Insured (Pounds Stirling)
	Sum Insured for Valuables
	Approximate Building Age		Please Select (Years) before 1800 1800-1900 1901-1920 1921-1945 1946-1980 1981-1990 1991 onwards
	Your Details
	Title		Miss Mr Mrs Ms
	Your Firstname
	Your Surname
	Correspondence Address (inc postcode)
	Email
	Contact Telephone Number
	Number of Years You have Owned This Property		Please Select (Years) 1 2 3 4 5+
	Claims made in last 5 years (enter 'none' if none)
	Date of Birth		01 02 03 04 05 06 07 08 09 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 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
	Approximately, what date would you require cover to start?		01 02 03 04 05 06 07 08 09 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 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Underwriting Questions
I/ We confirm the Property IS:-
In a good state of repair			Yes No
Built of brick, stone or concrete, with a pitched roof of slate or tiles			Yes No
Occupied solely as a private dwelling with no part of the property being used for any commercial purposes			Yes No
Protected by a minimum of 5 lever mortice deadlocks on all entrance doors			Yes No
If 'No' to any of above. please provide brief detail
I/ We confirm the Property is NOT:-
Showing signs of movement, structural alterations affecting load bearing walls during previous 5 years			Yes No
Underpinned, or has remedial action relating to landslip, heave or subsidence, or coastal/river erosion			Yes No
in a neighbourhood with a history of flooding			Yes No
A listed Building			Yes No
If 'No' to any of above. please provide brief detail
Has the Proposer or any member of their family normally residing with them, or has the Proposer, Fellow Directors or Partners...
Had an insurance declined, renewal refused, cover terminated or special terms imposed?			No Yes
Ever been declared bankrupt or been a director of a company that went into liquidation?			No Yes
Ever been convicted of any criminal offences?			No Yes
Had more than 2 claims or losses in the past 3 years, or a single claim or loss of over £1900 including legal disputes and court actions, on any property other than the property on which you are now seeking a quotation?			No Yes
If 'Yes' to any of above. please provide brief detail
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