1. When did the loss/damage occur?

2. Address or location where the loss or damage occurred

3. Is any Business conducted from the Home?

4. Please give particulars of any Building Society/Bank interest in the property if this claim is made under the Buildings Section of the Policy:

. Was the Home furnished and occupied at the time of loss or damage?

If ‘No’, when was it last:

6. Is the Home occupied by anyone other than a member of your family?

7. Are you the sole owner of the property lost/damaged?

8. Are there any other insurances covering the loss?

9. Have you any reason to suspect that the loss arose through the actions of any particular person?

10. Were the police advised of the loss/damage? (Theft/malicious damage) If ‘Yes’, state:

11. Describe the circumstances and cause of the loss or damage:

12. If your Policy is in joint names but you do not have a joint Bank Account, please indicate to whom any settlement cheque should be made payable:

13. Have you experienced any previous losses or claims within the last 3 years?

16. I/We declare all these particulars to be true and understand that you may ask for information from other insurers to check the answers I/we have provided.