Your Details:
Full Name:
Date of Birth:
(dd/mm/yyyy)
Secondary Name:
(Optional for Joint Policy)
Secondary's Date of Birth:
(Optional)
(dd/mm/yyyy)
Address Line 1:
Address Line 2:
Post Code:
Email Address:
Home Telephone:
Mobile Telephone:
Cover Required:
Building Insurance:
Yes
No
Contents Insurance:
Yes
No
Accidental Damage:
Yes
No
Property Ownership:
Owned on Mortgage
Owned Outright
Private Let Furnished
Private Let Unfurnished
Council Tenant
Other
Building Details:
Year of Build:
(yyyy)
Type of House:
Detached
Semi-Detached
Terraced
End Terraced
Bungalow
Flat
Number of Bedrooms:
Sum Assured Required:
(This is the value you want to insure for)
Content Details:
Sum Assured Required:
(This is the value you want to insure for)
All Risks Req Sum Assured:
(This is any additional objects you would like to insure e.g. Laptop)
Other High Valued Objects:
(Anything Unusual that you would like to insure should be stated here)
* Please Include the value of any additional objects that you want to insure. If you do not have any additional objects you wish to insure, then leave the fields blank.
Other Details:
Security:
5 Lever Locks:
Yes
No
Plastic Windows:
Yes
No
Alarm:
Yes
No
Neighbourhood Watch:
Yes
No
Claims:
This is where you should specify any previous claims that you have had. Be sure to include all details.
Current Insurance Premium:
(Optional)
Current Insurer:
(Optional)
Insurance Start Date:
(dd/mm/yyyy)
Any Additional Information:
If you feel there is any other information which you think is relevant and is not covered in the form then please specify in this box.
Macclesfield Insurance Services Ltd is authorised and regulated by the Financial Services Authority No.417382
