This form is designed for properties which are let to an individual or family unit where there is only one tenancy agreement in place. If the property is divided into Bedsits or there are more than one tenancy agreements in force, please e-mail us with the details. * Denotes Mandatory Field * Contact Name   * E-Mail Address   * Telephone Number   * Correspondence Address       * Post Code   * Risk Address       * Post Code     Current Insurers     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 2009 2010 2011 * Tenant Type   Working Person(s) Retired DSS Referal Council Support Students Asylum Seekers * Is the tenancy agreement   for a minimum of 6 months   Yes No * Property Type   Detached House Semi-Detached House End-Terrace House Mid-Terrace House Detached Bungalow Semi-Detached Bungalow End-Terrace Bungalow Mid-Terrace Bungalow Detached Maisonette Semi-Detached Maisonette End-Terrace Maisonette Mid-Terrace Maisonette Purpose Built Flat Converted Flat Other - Not Listed Above * Approx Year Property Built   * Wall Construction   Brick Brick/Timer Frame Stone Concrete Other - Not Listed Above * Roof Construction   Tile Slate Concrete Metal Other - Not Listed Above * What percentage of the roof is flat   felt on timber   None 1-10% 11-25% 26-50% Over 50% * Floor Construction   Timber Concrete Both Timber and Concrete Other - Not Listed Above * Stair Construction   Concrete Timber Metal N/A - No Stairs Other - Not Listed Above * Listed Building No Yes   If Yes, what grade   * Is there any history of Subsidence   Heave or Landslip in the   property or surrounding area   No Yes * Have you made any claims   in the past 5 years No Yes   If Yes, please give details     Buildings Sum Insured   If Required   Contents Sum Insured   If Required   Monthly Rental Income     Any Additional Information