"*" indicates required fields To confirm your eligibility for the Select range of insurance products please complete our short form below. If you are unable to obtain an online quotation then we are pleased to advise that our Bespoke listed home policies may be more suitable and the team will be in touch once we have received your information.This field is hidden when viewing the formPOLICY HOLDER DETAILSPolicy Holder Name: Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Name Last Name Email Address Address (Incl. Postcode):* Postcode Address Address Line 2 City State / Province / Region Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number:*Buildings Rebuild Value (Including Outbuildings)*In order to ensure that you have the correct cover, you need to specify an accurate rebuild sum for your property. This is different to the property’s market value and must reflect the full rebuild cost to reinstate the property as it was using appropriate materials and methods as instructed by your conservation officer. If you are unsure of the rebuild cost for your property, please speak to one of the team on 01795 844939 for assistance in arranging for a professionally qualified surveyor to advise on a suitable figure.Do you require contents insurance?* Yes No Contents Cover Required*When do you need cover by?* DD slash MM slash YYYY Is any part of the roof thatch?*YesNoHow did you hear about us?* We are pleased to advise that our Bespoke listed home policies may be more suitable. Please complete the remaining questions and the team will be in touch. Further DetailsDate of Birth:* DD slash MM slash YYYY Occupation:Employer:Current Insurer:Current Premium:Please opt-in below to receive relevant information from The Listed Property Owners’ Club via email, phone and post. Your data will not be passed on. You can unsubscribe at any time by calling 01795 844939 or using the unsubscribe links in the e-newsletter. More information can be found in our Privacy Policy.I am happy to be contacted with relevant information from LPOC via (please tick) Email Post Phone Remember, to receive the free LPOC newsletter The Listed Property Insider, which includes helpful information on the issues facing listed property owners, please opt-in to receive emails.Are you the owner of the property?* Yes No Is it a Joint Policy?* Yes No Joint Policy Holder Name:* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Name Last Name Date of Birth:* DD slash MM slash YYYY Email Address* Occupation:Employer:Phone Number:* PROPERTY DETAILSType of propertyDetachedSemi detachedEnd terracedMid terracedFlatOtherDwelling Type*1-3 Dwellings4+ DwellingsType of property*How many floors does the property cover in total?*OneTwoThreeFourFiveSixSeven +Is there a basement at the property?* Yes No Use of PropertyMain residence2nd residenceHoliday homeRental propertyMulti-tenantedUnoccupiedBusiness PremisesConstruction (Incl. Roof):Year Property BuiltIf you are unsure, then please enter your best estimate.Listed Grade*Grade IGrade IIGrade II*Category A (Scotland)Category B (Scotland)Category C (Scotland)Category A (Northern Ireland)Category B+ (Northern Ireland)Category B1 (Northern Ireland)Category B2 (Northern Ireland)Not ListedNo. of BedroomsOneTwoThreeFourFiveSixSeven +No. of Bathrooms / WC's*OneTwoThreeFourFiveSixSeven +Trees or shrubs within 20ft/7m of any building, which are more than 10ft/3m tall (Please provide species, height and distance):Has the property ever suffered from flooding, or is it in an area which has been subject to flooding? If so, please provide details:Are there any watercourses or sea within 400m of the property (if so please provide details):* Yes No DetailsAre there any watercourses or sea within 250m of the property (if so please provide details):* Yes No DetailsHas the property suffered from, or is it showing any signs of, subsidence, heave or landslip, other than historic settlement? If so, what happened and when?:Has the property ever been underpinned?YesNoAre there any bridges on your property or land? If so provide location, age, value and whether over water:Are the buildings or grounds open to the public? If so please provide details:Are all buildings (including outbuildings) in good condition? If no, provide details:What is the method of heating (oil, wood burners, open fires, central heating)?Are there any on-going or planned (within next 12 months) refurbishment/works at the property? If so: - What is being done? - What is the expected timeframe? - What is the budget of the works?Does any part of the property have a flat roof?* Yes No Roughly what percentage of the property has a flat roof?THATCHED PROPERTY DETAILSIf the property is semi-detached or terraced, is it attached to another thatched property, or tiled property?Is there any halogen lighting (excluding down lighters) used in the loft or attic space?YesNoWhat type of thatch is your roof? Fibre Thatch Long Straw Wheat Reed Water Reed What is the depth of the thatch? Less than 1 metre 1 - 2 metres 2 metres When was the roof last inspected by a professional thatcher? DD slash MM slash YYYY Is the roof in good condition and well maintained? Yes No When was the electrical installations last professionally inspected by a NICEIC qualified electrician? DD slash MM slash YYYY How many miles is the property from the nearest fire brigade?Please enter a number greater than or equal to 0.Are there fire extinguishers in the kitchen? Yes No Are there any additional fire extinguishers? Yes No Are there any heat and/or smoke detectors? Yes No Is there a smoke and/or fire extinguisher fitted in the roof void or highest point? Yes No Is there a fire alarm linked to a monitoring station? Yes No Are there fire barriers beneath the thatch? Yes No Has the roof been treated with a fire retardant? Yes No Are there any chimneys at the property? Yes No Are the chimneys at the property ever used? Yes No Are the chimneys lined? Yes No Do you have spark arrestors fitted to the chimneys? Yes No What height is the chimney above the ridge? less than 1.8m more than 1.8m What form(s) of heating are used? Gas Oil Electric Open Fires Solid Fuel Stove If you have open fires or solid fuel stoves in use, have the chimneys been swept within with the last 6 months? Yes No and has the chimney been inspected in the last 3 years by a HETAS registered company? Please provide a copy of the certificate, if available.YesNoIs the property connected to the mains water supply? Yes No HOW IS THE PROPERTY OCCUPIED?How is the property occupied?(Owner occupied as main residence, unoccupied, personal holiday home, holiday let, let to DSS, let to students, let to professionals?)Is there any business use at the property, including outbuildings? If so, provide details:Do you have any domestic staff? Do they live in and are they full time or part-time?SECURITY & FIRE PROTECTION INFORMATIONWhat security is in place on all exterior doors?Provide details of what is in place on each door (5 lever mortice deadlocks, Yale locks, etc.)What security is in place on all ground floor and accessible windows?(Key operated locks, latches, etc.)Is there an alarm in place? If so, is it: - Audible only, Central Station or Redcare? - Annually maintained?Is there any other security in place? (CCTV, Daytime occupancy, electric gates etc.):Is there a safe at the property? If so: - What type? (Wall, free standing, etc.) - Make & Model? - Cash rating of safe?What fire protection is in place? (Battery detectors, mains wired, central station fire alarm, fire blankets, fire extinguishers, etc.? COVER REQUIREDGeneral Contents:This figure should represent the total value of the possessions in your home, excluding valuables, which are specified separately. The cover needs to be sufficient to replace all of the items in your home at their full replacement cost (apart from clothing and linen which is subject to deduction for wear and tear)THE SUMS INSURED BELOW ARE IN ADDITION TO THE GENERAL CONTENTS (ABOVE):Pictures/PaintingsSUM INSUREDAntiquesSUM INSUREDPianoSUM INSUREDPrecious metals/gold and silver plated items (ex. jewellery/watches):SUM INSUREDSculpturesSUM INSUREDClocksSUM INSUREDStamps and other collectibles:SUM INSUREDWinesSUM INSUREDFursSUM INSUREDGunsSUM INSUREDFragile items (porcelain, china, etc.):SUM INSUREDOthers (Please specify the sums insured for each):Jewellery (Specified):SUM INSUREDJewellery (Unspecified):SUM INSURED ADDITIONAL INFORMATIONHave you had any claims in the last 6 years?*YesNoPlease detail a description of the claim(s), the date and the amount settled.Are you and everyone residing at the property a UK Resident?*YesNoHave you or anyone living at the property ever been refused insurance, or had any special terms imposed?*YesNoHave you or anyone living at the property ever been declared bankrupt, been subject to bankruptcy proceedings, entered into Individual Voluntary Agreement (IVA) or received a County Court Judgment (CCJ)?*YesNoHave you or anyone living at the property been charged with or convicted of any offence (other than motoring offences) received a police caution or have any pending prosecution that should be declared as per the Rehabilitation of Offences Act 1974?*YesNoGeneral information or outstanding matters:
