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Personal Details

Title:

First name:

Surname:

Date of birth:

Email address:

Are you a full-time student?

Yes No

Do you wish to include a second applicant?

Yes No

Second applicant title:

Second applicant first name:

Second applicant surname:

Second applicant date of birth:

Are you a full-time student?

Yes No

Property Details

Property house number and street name:

District:

Town:

County:

Postcode:

Property type:

Number of bedrooms:

Previous Claims

Have you, or anyone to be insured under this policy, made any contents insurance claims in the last 5 years?

Yes No

Elibigility

I/we meet all of the following eligibility criteria:

Neither I, or anyone to be insured under this policy, have any unspent convictions or prosecutions pending (other than motor convictions)

Neither I, or anyone to be insured under this policy, have had insurance cancelled, declined, declared void or had any special terms imposed as a result of non-disclosure of information, fraudulent activity or misrepresentation, whether intentional or not

The property will not be left unoccupied for more than 60 days in a row

The property will not be used for business or professional purposes, other than clerical work:

Yes No

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