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Quotation form for household insurance
Page
1
of 3
Information about the subscriber
Title
Please select
Mr
Mrs
Miss
First name
Last name
e-mail
*
Phone
Date of birth (dd/mm/yyyy)
dd/mm/yyyy
Next
Information about the premises to be insured
Address of premises to be insured
*
Town where premises are located
*
Town ZIP Code
*
Quality
*
Please select
Owner
Renter
Co-owner
If rented ?
*
Please select
Furnished
Unfurnished
Type of Premises
*
Please select
Appartment
House
Occupancy of premises, are you
*
Please select
Occupant
Non occupant
Are the premises left unattended more than 60 days/year (in total)?
*
Please select
Yes
No
Number of main rooms (any room over 30m² counts double, excluding kitchen, bathroom)
*
Total surface (Square meters) including garage and cellar
*
Building construction date
*
Contents sum insured in Euros
*
Valuable items in Euros
*
On the property to insure, do you have ?
Outdoor furniture
Swimming pool
Fire detectors
A fire place
On which floor are the premises located ?
Please select
Ground
Intermediary floor
Top floor
Have you had any claims last two years ?
Please select
Yes
No
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Additional infos
You can ad any additional info bellow
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