Schemes
Company
Correspondence Details
Insured Name
Agent Name
Point of contact:
Title
Mr
Ms
Mrs
Miss
Dr
Rev
First Name
Last Name
Email
Telephone
Insurance renewal date
Correspondence Address
Address Line 1
Address Line 2
City
County
Postcode
Country
Premises Details
Number of Flats
Number of Houses
Number of Commercial Premises
Have the insured had any claims in the last 5 years?
Yes
No
Incident date
(approx.)
Cause
Settlement Amount
Add another claim
Premises Address
Address Line 1
Address Line 2
City
County
Postcode
Country
