Your details

1. Title Dr Mr Mrs Miss Ms *
2. First name *
3. Surname *
4. Date of birth (dd/mm/yyyy) *
5. Are you a BCA Member? Yes No *

Property details

1. House Name / Number *
2. Street Name *
3. Town *
4. County
5. Postcode *
6. Number of bedrooms 1 2 3 4 5 6 7 *

Contact details

1. Email *
2. Phone number *
3. Preferred contact time *

Insurance details

1. Have you held home insurance for more than 3 years? Yes No *
2. Renewal date (dd/mm/yyyy) *
3. Current Insurer
4. Current Premium
5. How many claims have you had in the last 3 years? 0 1 More than 1 *

Buildings Cover

1. Do you require cover for buildings? Yes No *

   Cover definition and benefits

   1. We provide £500,000 as standard. Is this adequate? Yes No
   2. Enter building sum insured required

Contents Cover

1. Do you require cover for contents? Yes No *

   Cover definition and benefits

   1. We provide £75,000 as standard. Is this adequate? Yes No
   2. Enter total contents sum insured required

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