Name(s) of Policyholders(s) First Policy Holder Date of Birth Second Policy Holder Date of Birth Occupation(s) Contact Telephone Number(s) Email Address RENEWAL OR PREFERRED QUOTATION DATE * * To give you plenty of time we will contact you 3-4 weeks before this date.

Risk Address & Post Code Type of Property

Flat

Bungalow

Chalet Bungalow

House

Other

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Terraced

Detached

Link-Detached

Semi

Cost to Rebuild (If in doubt, the market value may give an approximate idea. Although often higher than needed as it includes the value of the land) Construction
(Walls)

Brick

Stone

Timber

Cob

Other

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(Roof)

Tile

Slate

Thatch

Other

Does the property have area(s) of flat roof?

Yes

No

what percentage of the total roof is flat?

Year Built Is the property a listed building?

Yes

No

Number of Bedrooms
Number of bathrooms/shower rooms/ensuites?
Has there been a history of, or are there any signs of subsidence/landslip/heave?

Yes

No

Is the property in an area which has suffered flooding (within 400m)?

Yes

No

Does your property have French doors or Patio doors?

French Doors

Patio Doors

N/A

What is the total replacement value of your contents as new?
To cover personal belongings taken away from home, what is the maximum amount taken out by you and your household at any one time?

Approximately how long have you been claims free?
Is there any other information you would like to give us? Are you happy to receive marketing communications from Cowens?

Yes

No