Please complete the short form below or fax it through to 01424 217107 or phone it through to us on 01424 220110

If you have been declined HOUSEHOLD insurance for any reason please complete and submit the short form below and one of our advisors will be in contact with you within 48 hours. Alternatively you can telephone us on 01424 220110 or email any questions you may have to cover@cantgetinsurance.co.uk

Please complete for an indication of premium – and tick as appropriate

E-mail Address*

Daytime contact number*


First name*


Date of Birth*

Full time occupation*

House number or name*


Type of property. Please tick as appropriate *

Approximate age of property*

Approved door and Window Locks*


Sum insured Buildings.
This should represent the rebuilding costs £*

Sum insured contents.
This should represent the cost of replacing
your items as new £*

Personal effects away from the home. £*

Any other. Description and value*

Type of cover required i.e

Contents -Standard Cover*

Accidental Damage*

Any claims in last six years?*

If "yes", how many?

Have you or any person living at the property
ever had any criminal convictions
other that driving offences?*

Has the property ever had subsidence?
Survey may be required.*

Has the property ever been flooded?*

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