Home Insurance – Assessment of Demands and Needs

Insurance Brokers, Companies and Intermediaries

Other Insurance Brokers, Insurance Companies or Insurance Intermediaries that you have approached for quotations to date

Are you an Existing MIB Customer?*

Yes
No

Please specify your Customer Number

Policy Holder Details

Name*

First Last

ID Number*

Date of Birth*

Email*

Enter Email Confirm Email

Contact Phone Number*

Business/Occupation*

Postal Address*

Street Address Address Line 2 City ZIP / Postal Code Country

Additional Policy Holders

Name	ID Number	Date of Birth
			Edit Delete
There are no Policy Holders.

Maximum number of policy holders reached.

Loss/Claim History

Details and amounts of any previous losses and/or claims

Accident Details
	Edit Delete
There are no Losses.

Maximum number of losses reached.

Is the Property already insured?*

Yes
No

Current Insurance Company

Name of the current insurance company the property is insured with, if applicable

Insurance Refusal*

Have you ever been refused insurance?

Yes
No

Convictions*

Do you have any previous convictions?

Yes
No

Property to Insure

Address*

Address of the property to be insured

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Garage

Address of any garage to be insured

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Private Residence?*

Is the property occupied solely as a private residence?

Yes
No

Permanent Residence?*

If the property your permanent residence or a holiday home?

Permanent Residence
Holiday Home

Is this Property*

Occupied
Unoccupied for more than 90 consecutive days
Rented Out
Or any part of the property used for Commercial Purposes

Maximum days in a row that the property may be unoccupied*

Up to 30 days
Up to 60 days
Up to 90 days
Over 90 days

Is the property:*

An Apartment / Maisonette
Terraced House / Villa

Please indicate whether you have any of the following features installed in your home*

Photovoltaic Panels
Intruder Alarm
Fire Alarm
None of the above

Buildings*

Sum Insured for Buildings

Please enter a number greater than or equal to 0.

Contents*

Sum Insured for Contents

Please enter a number greater than or equal to 0.

Separate Sum Insured for PV Panels*

Please enter a number greater than or equal to 0.

Are you the sole owner of the property to be insured?*

Yes
No

Details of Co-Owners

Is the property secured by an Alarm or CCTV?*

Yes
No

Is the policy required for bank loan purposes?*

Yes
No

Please specify the bank

Personal Belongings / Valuables Outside the Home

Current replacement value of items/valuables to be insured

Item/Valuable Description	Item/Valuable Current Replacement Value
		Edit Delete
There are no Items.

Maximum number of items reached.

Special individual Items / Valuables Inside the Home

List and provide details of any Special individual Items / Valuables you may wish to insure inside the Home

Item/Valuable Description	Item/Valuable Current Replacement Value
		Edit Delete
There are no Items.

Maximum number of items reached.

Additional Details

Property Owner*

Do you already own the property or are you in the process or purchasing it?

Owner
Purchasing

Work from Home

Do you carry out ant work from your home, or see to clients in part of the property? Give details.

Additional Policies

Details of any other insurance policies that you may consider transferring and placing through us

Additional Comments

Attach any relevant documents.

Drop files here or

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Terms Accept*

I have read and accept MIB's Client Terms of Business & Privacy Policy.*

I understand that by completing this form the data will be processed by MIB in line with GDPR and hereby consent that this data (including if needed sensitive data as defined in article 9 of GDPR) are used for the purposes of providing your insurance services.

I also understand that it is my responsibility to secure and hold the necessary consent from any employees, beneficiaries or other third parties direct or indirectly involved in the insurance proposal/arrangements and whose data will be processed by MIB and the providers of insurance and ancillary services.

Home Insurance – Assessment of Demands and Needs

Policy Holder Details

Property to Insure

Additional Details

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