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020 8335 3388
enquires@siagroupltd.com
Mon-Fri 9AM-5:00PM
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020 8335 3388
enquires@siagroupltd.com
Mon-Fri 9AM-5:00PM
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Home
Business Insurance
Personal Insurance
Forms
Trusted Partners
Claims
Home
Business Insurance
Personal Insurance
Forms
Trusted Partners
Claims
Contact Us
Home
Business Insurance
Personal Insurance
Forms
Trusted Partners
Claims
X
Home
Business Insurance
Personal Insurance
Forms
Trusted Partners
Claims
Home
Business Insurance
Personal Insurance
Forms
Trusted Partners
Claims
Contact Us
Household Quotation Request Form
"
*
" indicates required fields
Client Details
Client name
Contact Telephone Number
Email
Client Date of Birth
Day
Month
Year
Partner/Joint insured
Partner/Joint Date of Birth
Day
Month
Year
Occupation and nature of employer’s business (or own, if self employed)
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Year Built
Flat roof %
Listing grade
Please Select
1
2
3
Property type e.g. detached, semi, flat (if flat include the floor it’s on)
Total no. of floors
Please Select
1
2
3
4
5
6
Total no. of bathrooms
Please Select
1
2
3
4
5
6
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)
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)
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 Surrey Independent Advisers. Please tick the box to confirm you are happy with this.
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