* Denotes Mandatory Field * Name * E-Mail Address * Telephone Number * Correspondence Address       * Post Code * Risk Address       * Post Code   Current Insurers (if any) * Date Due/Cover Required 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st January February March April May June July August September October November December 2012 2011 2010 * Reason for Unoccupancy Awaiting Sale Due to Death Between Tenants Awaiting Tenants Owner in Nursing Home Owner in Hospital Living/Working Abroad Awaiting to Move in Undergoing Renovations Other - Not Listed   Please give details of any   works to be carried out * What is the construction of the   walls of the property Brick Brick/Timber Frame Stone Concrete Other - Not Listed * What is the construction of the   roof of the property Tile Slate Concrete Metal Other - Not Listed * What percentage of the roof   is flat felt None 1-10% 11-25% 26-50% Over 50% * Is the property fitted with 5 lever   mortice deadlocks on all the final   exit doors Yes No * Is the property fitted with key   operated window locks on all   accessible windows Yes No * How often is the property inspected   internally Daily Every 2-3 days Weekly Fortnightly Never Other - Not Listed * Is the property furnished for normal   habitation Yes No * Have you made any claims on this   or any other property in the last 5   years Yes No   If Yes, please give details   Buildings Sum Insured   (If Cover Required)   Contents Sum Insured   (If Cover Required)   Any Additional Information