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Central Insurance Services Home and Drive Quote Form

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Central Insurance can quote on all or individual sections below please fill out the sections that apply to you:

Full Name :

Contact Telephone Number :

Email Address :

Date Of Birth :
(dd/mm/yyyy)

Occupation :

Address :

Postcode :

Home Details:

Buildings rebuild cost (£) :

Contents Total (£) :

Personal Possessions / All Risks (Items under £2,500) :

Specified items over £2500 :

Type of property :

Use :

Year or Decade of Construction :

Number of bedrooms :

Previous Claims

Is the final exit door secured by a deadlock conforming to BS3621 or with a minimum of 5 lever or alternately a multi point locking system which incorporates a lever or deadlock which is capable of being secured by a key from both sides of the door?

Are all other external doors protected by a deadlock conforming to BS3621 or with a minimum of 5 lever or key operated security bolts operating horizontally internally top and bottom or a multi point locking system which incorporates a lever or cylinder deadlock which is capable of being secured by a key from both sides of the door?

Are the opening ground floor windows secured by a key operator window locks

Are all accessible upper floor windows secured by key operated window locks

Is your home protected by an alarm system

If YES : is it under a maintenance contract by an NSI or SSAIB company

Which Signaling method is used

Travel:

What travel insurance do you require ?

is any applicant aware of any sign or sympton for which they have not yet consulted a doctor?

Is any applicant awaiting in-patient, day-patient or out-patient treatment?

Has any applicant received in-patient, day-patient or out-patient treatment in the last 12 months?

Motor Details:

Vehicle 1 details:

Make:

Model:

CC:

Year:

Value:

Vehicle 2 details (if applicable)

Make:

Model:

CC:

Year:

Value:

Any further vehicle / details :

Any additional information :

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Contacts

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Email
+44 (0)1224 656623

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