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Supporting Brent Lodge Wildlife Hospital with Eden Associates

Request a quotation, and if you take out your insurance through us, we will donate up to 25% of our commission to Brent Lodge Wildlife Hospital.

Make A Different Choice, Make It Evergreen

Household Quotation Request Form

"*" indicates required fields

Client Details

Title

Client name

Client Date of Birth

Day

Month

Year

Contact Telephone Number

Email*

Occupation and nature of employer’s business (or own, if self employed)

Partner/Joint insured

Partner/Joint Date of Birth

Day

Month

Year

Partner/Joint insured - Occupation and nature of employer’s business (or own, if self employed)

Renewal premium and current insurer

Target premium

Renewal Date

Day

Month

Year

Risk Details

Address of property to be insured + Correspondence address.

Street Address Address Line 2 City County Post Code Country

Year Built

Flat roof %

Listing grade

Property type e.g. detached, semi, flat (if flat include the floor it’s on)

Total no. of floors

Total no. of bathrooms

Construction of walls and roof e.g. BSST, lath and plaster, timber

Number of years owned?

Number of bedrooms

Is the property: -

Main residence

Unoccupied

Overseas Property

Holiday home

Let

Specify type of let

Is the property used for any business purposes other than clerical?

Yes

No

Please advise what business is carried out, any visitors, how business is advertised etc

Does the property have a history of subsidence heave or landslip or are there any signs of subsidence?

Yes

No

Reports may not be required if completion of work was over 20 years ago.

Any trees/vegetation more than 5metres high within 10 metres of the any part of the property?

Yes

No

Please advise type of tree, height and distance away from property.

Does the property have a history of flooding or is it located within 400m of a watercourse or the sea?

Yes

No

Please advise distance away from watercourse, height above the waterline and any flood defences.

Is the property due to undergo, or undergoing renovations or works during policy period?

Yes

No

Does the property have minimum physical security? e.g. five lever deadlocks and key operated window locks

Yes

No

Have you ever had insurance cancelled, renewal declined or any additional terms imposed?

Yes

No

Have you, whether insured or not , made any claims or incurred any losses or damage during the last five years?

Yes

No

Claim 1

Date

Day

Month

Year

Type

Cost

Claim 2

Date

Day

Month

Year

Type

Cost

Claim 3

Date

Day

Month

Year

Type

Cost

Claim 4

Date

Day

Month

Year

Type

Cost

Claim 5

Date

Day

Month

Year

Type

Cost

Is the property protected by an intruder alarm?

Yes

No

If yes, is the alarm maintained by a NACOSS/NSI/SSAIB approved firm?

Yes

No

Do you have a safe?

Yes

No

If yes, what type of signalling

Digital dialler

Bells only

REDCARE

Other

Safe Make and model

Buildings Cover

Sum insured (Main home/tenants improvements)

Outbuildings

Tennis Courts, Annexes, Swimming pools

Garages

Voluntary excess (if required)

£250

£500

£1000

Other

(Compulsory excess automatically applies to buildings cover)

Is accidental damage cover required?

Yes

No

Contents Cover (A)

General contents

Paintings / Fine Art

Antiques

Gold / silver / plate

Books

Clocks / barometers

Porcelain / glass

Statues / sculptures

Student Contents

Memorabilia / Other

Please specify

Voluntary excess (if required)

£250

£500

£1000

Other

(Compulsory excess automatically applies to buildings cover)

Is accidental damage cover required?

Yes

No

Total Sum Insured (A)

Valuables Cover (B)

(Specify valuables over £5,000)

Unspecified total

Specified total

Jewellery *****see notes

Jewellery - Unspecified total

Jewellery - Specified total

Jewellery in the bank

Jewellery in the bank - Unspecified total

Jewellery in the bank - Specified total

Guns

Guns - Unspecified total

Guns in the bank - Specified total

Wine collections

Wine collections - Unspecified total

Wine collections - Specified total

Collections (please specify e.g. stamps, coins, books)

Collections - Unspecified total

Collections - Specified total

Other (Include outdoor items including mowers etc.)

Other- Unspecified total

Other- Specified total

Voluntary excess (if required)

£250

£500

£1000

Other

(Compulsory excess automatically applies to buildings cover)

Total Sum Insured (B)

Total Sum Insured (A+B)

Additional Information / Material facts / Criminal Convictions / Bankruptcy

Please list below any additional information required or that you feel may help underwriters in assessing the risk

We will only use the information submitted in this form to make contact with you regarding your enquiry. Your details will be stored securely and will never be passed to third parties outside of the quoting for and arrangement of your insurance or communications from Evergreen. Please tick the box to confirm you are happy with this.*

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Please check this box to confirm you are happy to receive the Evergreen e-newsletter.

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Please check this box to confirm you are happy to receive e-communications from our charity friends.

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Evergreen Insurance Services is a trading name of Surrey Independent Advisers Limited, who is authorised and regulated by the Financial Conduct Authority. FCA Number: 228148.
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