Gothic Insurance Brokers Ltd
Gothic House
Station Rd, Old Harlow
Essex CM17 0AP

Tel – 01279 429024
Fax – 01279 433383
Email – enquiries@gothicinsurance.com

Household Insurance Quote

(with Criminal Convictions)

Please fill as much information as possible on the form below to enable us to find the ideal policy for your situation.

Where did you hear about us?

If other please specify:

About you
Title
Sex
First Name(s)
Surname
Date of Birth
Marital Status
Occupation
Type of business
Is policy to be in joint names?
Joint Policyholder	(If required)
Title
Sex
First Name(s)
Surname
Date of Birth
Marital Status
Occupation
Type of business

House Name / Number
Full Address
Postcode
Email Address
Telephone Number

About your convictions	(please list 1,2,3 in each section if you have more than 1 conviction)
Name of Person with Conviction
Date of Offence
Date of Conviction
Type of Conviction (e.g GBH, Common Assault)
Sentence given by court (e.g. 5 years custodial or 100 hrs community service)
Sentence actually served (e.g. served 2 years then 3 months on tag)
Description of Incident (Please give as much information as possible)
Mitigating Circumstance (e.g. had drink problem at time now recovering alcoholic etc.)
Property details
Property type
No. of Bedrooms
Wall Construction
Roof Construction
Year built
Listed Building
Is the property in an area with a history of floods?
Ownership Years Property Owned?
No. of Adults at Property
No. of Children
Are you the main sole occupants?
Any paying guests?
Are there key operated window locks?

Buildings Cover
Is Buildings Insurance required?
Cost to rebuild property / Sum insured
Is Accidental Damage cover required
How many years no claims on previous buildings insurance?

Contents Cover
Is contents cover required?
Total Sum Insured
Is Accidental Damage required?
Do you require cover for personal belongings outside the home?
If so, sum insured outside the home
How many years no claims bonus on previous contents cover?
Has your current insurer declined to renew or cancelled your policy? If so, please give details
Please list any valuables over £1,500 (Jewellery, furs, antiques, works of art etc.)

General Questions
Please give FULL details of any claims made on either Buildings or Contents insurance within the last 5 Years

Date Cover to commence
Current renewal premium, if applicable
Current Insurer, if applicable

01279 429024

Authorised & Regulated by the
Financial Service Authority
Firm Number: 300031

Gothic Insurance Brokers Ltd. is registered in England. Company Reg. Number 880423. Registered Office: Gothic House, Station Rd, Old Harlow, Essex CM17 0AP