You can submit an enquiry on-line by completing the form below and clicking the 'send' button. Alternatively, you can print out this form by clicking the 'print' button and fax it us. Fields marked with an asterisk must be completed.

Broker Details
Broker Name*		Contact Name*
Tel No*		Fax No
Email*
Please indicate your preferred method of contact		Telephone Email
Client Details
Title*		Surname*
First Name*		Date of Birth*
Occupation
Address of property to be insured
Address*
Address
Town*
City*
Post Code*
If your client has a second property requiring cover, tick here

Sums To Be Insured
A - BUILDINGS	Main Residence	£
	Outbuildings	£
	Tenant's Improvements	£
B - CONTENTS	Exclude C and D below from contents	£
C - FINE ART	Fine art, pictures, books, furniture, rugs, etc	£
	GSP / Precious Metals	£
	Others - Please describe	£
D - VALUABLES	Jewellery & Watches	£
	Furs	£
	Jewellery & Watches kept only in a safe within the home	£
	Jewellery & Watches kept only in a bank or safe deposit	£

About your clientís home
1.	Property construction date*
2.	Type of Property*
3.	Number of bedrooms*
4.	Is the property of standard construction?*	Yes No
5.	Is it the clientís main residence?*	Yes No
6.	Is the property free from signs or history of cracks, subsidence or flooding?*	Yes No
7.	Is the property used for business?*	Yes No
8.	Is your client undertaking any building works?*	Yes No
If you have selected any of the shaded options above, please provide details here:

Security of the property Which of the following is at the property
1.	Key operated locks on accessible window and patio doors?*	Yes No
2.	5 lever mortice deadlock on main access doors?*	Yes No
3.	Safe or strongroom?*	Yes No
4.	Alarm?*	Yes No
Please indicate

Has the client made any claims in the last five years?		Yes No


If yes, please provide details, including the total amount of the claim?

Current Insurer & Premium

Where did you hear about SmithGreenfield?
Other (please state)


We will hold your details on file for our purposes only and will only pass the information to relevant insurers in order to obtain quotations. Cover is subject to completion of a satisfactory application form. Smith Greenfield Services Plc is not responsible for advice obtained from other sources with regard to the rebuilding cost of your home or contents.