Prestige Household Proposal
Please do not hesitate to contact us if you require assistance
completing the form – Tel: 01483 426300
Proposer Details  (Step 1 of 7)
How many properties require cover?
1 2 3 4 5

Is the policy to be issued in joint names?
Yes No

Title:

Mr, Ms, Mrs, ...

Forename(s):

Surname:

Contact telephone no.:

Contact email:

Correspondence address:

Post code:

Date of birth:

Occupation:

Industry:

Domestic partner's title:

Forename(s):

Surname:

Date of birth:

Occupation:

Industry:

Do you or your partner smoke?:
Yes No

If you answer Yes to any of the questions below please supply full details on the Additional Information page (final step).
Has any person to be insured:
Ever had a proposal for insurance declined, renewal refused, cover terminated, increased premium requested or special conditions imposed by any insurer?
Yes No

Ever been convicted of, or cautioned for (or charged with but not yet tried for) any criminal offence (other than motoring offences)?
Yes No

Ever been declared bankrupt or insolvent?
Yes No



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