Household Enquiry Form (fields with * are mandatory) Title MrMrsMiss Firstname* Surname* Address Email Date of Birth Occupation Name of Current Motor Insurer Sum Insured Required on Buildings € The sum Insured should be based on rebuilding cost, plus an amount of 12.5% of the sum insured to cover architect's and surveryor's fees. Is the building alarmed? Yes No If so is it to IS199 (Irish Industry Standard)? Yes No Is it linked to a monitoring station? eg. Eircom Phonewatch Yes No Sum Insured Required on Contents 30% 50% Sum Insured€  Location of Buildings Please select the location of the buildings to be insured. Please select the location of the buildings to be insured. Carlow Cavan Clare Cork County Cork City Donegal Dublin County Dublin 1 Dublin 2 Dublin 3 Dublin 4 Dublin 5 Dublin 6 Dublin 7 Dublin 8 Dublin 9 Dublin 10 Dublin 11 Dublin 12 Dublin 13 Dublin 14 Dublin 15 Dublin 16 Dublin 17 Dublin 18 Dublin 20 Dublin 22 Dublin 24 Galway County Galway City Kerry Kildare Kilkenny Laois Leitrim Limerick County Limerick City Longford Louth Mayo Meath Monaghan Offaly Roscommon Sligo Tipperary Waterford Westmeath Wexford Wicklow Property Details Is the property occupied by you and/or your family solely for residential purposes? Yes No If it is a Holiday Home please advise Is the property let, converted into flats or are paying guests received? If so please advise occupation of tenants and no. of them. Yes No Number of Bedrooms? Does the Property have Smoke Detectors installed? Yes No Optional Cover Available All Risks If extra All Risks cover on valuables and personal effects is required please tick the preferred option below: All Risks Specified Items Is cover required for any specified single article that exceeds the limit under the selected option? Yes No If "Yes" please enter the details below:(Note: A Valuation is normally required for articles valued over €2,600);   Decription of Item Sum Insured (€) Is this a Bicycle? 1. -- Yes No 2. -- Yes No 3. -- Yes No 4. -- Yes No Accidental Damage Cover Is Accidental Damage Cover Required? Yes No Claims History (Records with empty Claim Date will not be saved.) Have there been any claims in the past 3 years? Yes No Date Circumstances Amount Paid Additional Comments