Please take care to complete this form fully and correctly and to disclose all material facts which are likely to influence our acceptance and assessment of your proposal. If you are in any doubt about whether or not a fact is material, you should disclose it. Omission or mis-statement may affect the settlement of claims under the policy or make the Policy invalid. It is important that you insure for the full value of the property as otherwise your claim may be prejudiced.

Please complete the form in BLOCK Capitals

Full Name of proposer(s)                                           Telephone     

Address of Property to be insured                                 Post Code    

Communication Address if different from above        

Post Code                                             Telephone                 

Your Date of Birth       (dd-mm-yyyy)                                                    Spouse/Joint Proposer     

Occupation of   a) Proposer                                                             b) Spouse     

Date you require cover from       (dd-mm-yyyy)                                Is this proposal for an additional home ?   Please Select Yes No

Section 1

Buildings    Please Select Yes No                                                                                                                                                                             AMOUNT

Accidental Damage Extension    Please Select Yes No                                                                                                                                   £   

The sum to be insured must represent the full rebuilding cost, i.e. Building of the private dwelling house, outbuildings used for domestic purposes, fences, walls, gates, swimming pools including architect's and surveyor's fees, Local Authority charges and costs of debris removal.

Are the external walls of your home built of brick, stone or concrete ?     Please Select Yes No

Is your home a :     Please Select Terraced/Semi-detached house ? Terraced/Semi-detached bungalow ? Falt/Maisonette ? Other ?            If Other (please specify)    

What year was you home built ?      

Does you home have Gas central heating ?     Please Select Yes No

Section 1 - Buildings contents

Please provide details of Bank/Building Society if building is subject to a mortgage

Name of Bank/Building Society            

Address of Bank/Building Society         

Account No.    :                               

Section 1 - contents

                                                       Please Select Yes No                                                                                                                             £   

Accidental Damage Extension     Please Select Yes No

The sum to be insured must represent the full replacement value as new expect in respect of wearing apparel and household linen. Valuables - comprising gold and silver articles, jewellery, furs, cameras, binoculars, pictures and other works of art, collections of stamps, coins and medals should not exceed one third of the sum insured and the value of any single article if greater than 5% of the Sum Insured should be specified below. Items that are Insured under Section 4 - "All Risks" (except those covered under item 1 Personal Effects) should be excluded from this Section.

Note : Evidence of value must be submitted for any article valued at £750 or more.

Items of greater value than 5% of Total Sum Insured.

Items                                                                                Description                                                                                                            Sum Insured

1                                                                         £   

2                                                                         £   

3                                                                         £   

4                                                                         £   

Section 3 - LIABILITY  Automatically Included   £2,000.000

Section 4 - "All Risks"    Please Select Yes No

Only acceptable with Section 2 - Contents. Do not include any property which is to be insured only under Section 2.

Item  1                  Personal effects and clothing ( excluding furs, jewellery, gold and silver articles

                              and sports/golf equipment ).                                                                                                                                        £   

Item  2                  Miscellaneous jewellery, furs, watches, personal ornaments, gold and silver articles.

                             Cameras and sports equipment.                                                                                                                                    £   

Item  3                  Personal money, Credit Cards } maximum together £750.                                                                                               £   

Item  4                  Specified items of jewellery, furs, watches, personal ornaments

                              gold and silver articles and cameras.                                                                                                                             £   

                              Note : Evidence of value must be submitted for any article valued at £750 or more.

Items of greater value than 5% of Total Sum Insured.

Items                                                                                Description                                                                                                            Sum Insured

1                                                                        £   

2                                                                        £   

3                                                                        £   

4                                                                        £   

Section 5 - Frozen Food

                                                             Please specify make/model of freezer   Please Select Yes No                                                              £   

Make                            Model                           Year of Manufacturer     

General Questions

Please answer the following questions and select the relevant box, where applicable and if appropriate provide details.

1    (a)   The whole of the building is occupied by me and members of my family for private residential purposes.    Please Select Yes No

      (b)   Is self-contained ?     Please Select Yes No

      (c)   Has its own lockable entrance door ?     Please Select Yes No

      (d)   If above a shop is there direct access to residential portion ?     Please Select Yes No

2     Is any part of the building used for trade, professional or business purpose ?     Please Select Yes No

       If Yes, please provide details

3     Is the building ?

      (a)   constructed solely of brick, stone or concrete and roofed with slates, tiles, concrete, asphalt or metal ?     Please Select Yes No

       If No, please provide details including whether any part of the roof is flat and covered with felt

      (b)   in good repair and will be so maintained ? If no, please provide details     Please Select Yes No

      (c)   exposed to flooding, landslip, subsidence or coastal erosion ?

      (d)   Front and rear exit doors fitted with British Standard 5 Lever Mortice deadlocks     Please Select Yes No

      (e)   Accessible windows fitted with window locks     Please Select Yes No

      (f)   Fitted with a Burglar Alarm     Please Select Yes No

      (g)   If Yes to (f), is it subject to a maintenance contract ?     Please Select Yes No

4     Is the address to which cover applies ?

      (a)   left regularly unoccupied ? If Yes, please provide details     Please Select Yes No

      (b)   a flat ? If Yes, please provide details     Please Select Yes No

5     Have you as proposer or any person to be insured made any claims or sustained any losses in respect of the risks now proposed within the

       last 3 years ?     Please Select Yes No

       If Yes, please provide details

6     Has any Company or Underwriter ever declined to accept or renew the insurance now proposed to

       or imposed terms ?    Please Select Yes No

       If Yes, please provide details

7     Have you or any person to be insured previously held a policy with CIB Ltd ?     Please Select Yes No

       If Yes, please provide policy number