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  First we need to know about you, the insurance you want and the things that are causing you problems in getting covered.  
 
Insurance Wanted
 
 
Your Title  
 
 
First Name  
 
 
Surname  
 
 
Your Date of Birth  
Day   Month   Year
   
 
   
 
Work Telephone  
 
 
Mobile Telephone  
 
 
Email Address  
 
 
Your Current or Last Insurer  
 
 
Your policy renewal date
(even if cancelled)
 
 
  Please tell us of the specific issues affecting your insurance - Please tick all that apply  
 
  Your insurer has cancelled or voided your policy
 
 
  Your insurer will not renew your policy
 
 
  Your property (or neighbouring property) has suffered from Subsidence, landslip or heave
 
 
  Your property is of "non standard" construction
 
 
  Your property is a listed building
 
 
  Your property is empty, regularly left empty or a holiday home
 
 
  You want to insure high value items
 
 
  Your property has been flooded or is in a high flood risk area
 
 
  You, or someone living with you, has a criminal conviction
 
 
  Other - Please give details below
 
  Please use the box below to tell us of anything else you consider relevant  
 
 
 
Go to the next page
 
 
 
Criminal conviction Insurance Divider
 
 

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Home Insurance Help is a trading style of
Platinum Financial Consulting
The Old School House, East End Road
Bradwell-on-Sea, Essex, CM0 7PY

Telephone : 020 33 55 4831            Fax : 0871 277 1422            Email : info@platinumifa.co.uk

AUTHORISED AND REGULATED BY THE FINANCIAL CONDUCT AUTHORITY

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FSA Registration Number : 227014

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