Gothic Insurance Brokers Ltd
Gothic House
Station Rd, Old Harlow
Essex CM17 0AP

Tel – 01279 429024
Fax – 01279 433383
Email –






Let Property Insurance Quote

Quotes emailed to you within minutes (during office hours

Where did you hear about us?

If other please specify:

About you




First Name(s)


Date of Birth
Marital Status
Type of business
Correspondence Address
House Name / Number
Full Address
Email Address
Telephone Number
Risk Address
House Name / Number
Full Address

Risk Property details

Property type
No. of Bedrooms
Wall Construction
Roof Construction
No. of Storeys

Year built
Listed Building
Is the property in an area with a history of floods?
Are there key operated window locks?

Buildings Cover

Is Buildings Insurance required?
Cost to rebuild property / Sum insured
Is Accidental Damage cover required
How many years no claims on previous buildings insurance?

Landlords Contents

Contents cover required?
Total Sum Insured
Is Accidental Damage Cover required?
How many years no claims bonus on previous contents cover?

Tenancy Details

Duration of Leasing Agreement?
Leasing agreement will be between the freeholder and the -
Does the tenancy agreement allow tenant to sublet?

Number of Tenants?

Note1: If the property being occupied is a flat(s), please indicate the maximum number of tenants in any one flat.
Note2: A family is considered as 1 Tenan

Type of Tenants?

Note: If the premises are multi-tenured, indicate the catagory of tenant with the highest risk (#(i) being the highest risk, #(vi) the lowest)

Will cooking be allowed in any area other than a clearly designated cooking area

Risk Statement



You or any other joint owners have never:

  1. Suffered any loss or incurred any liability, whether insured or not, during the last 3 years as a result of the risks proposed (whether at this or any other premises) or had any claims made against you?
  2. Been convicted of, or in the course of being charged with, any offence (excluding driving offences) whether at these premises or elsewhere?
  3. Been declared bankrupt or been a director of any company that went into liquidation?
  4. Had any insurance declined, cancelled, refused or had any special terms applied by any Insurer for the risks proposed?

The premises are:

- In a good state of repair and will be so maintained
- Heated solely by oil and/or electricity and/or mains gas and/or solid fuel
- Not close to cliff, quarry or other excavation
- Are not showing any sign of existing or previous damage by Subsidence, Heave or Landslip
- Free from any underpinning or any remedial action with regard to subsidence, heave or landslip

- No part of the property is used for commercial business
- No structural alterations or renovations involving load bearing wall are in progress or planned
- No part of the property is flat roofed

Do you agree with the above statements?

If no, please state reasons why:

General Questions

Please give FULL details of any claims made on either Buildings or Contents insurance within the last 5 Years
Date Cover to commence
Current renewal premium, if applicable
Current Insurer, if applicable



TELEPHONE: 01279 429024
01279 429024

Authorised & Regulated by the
Financial Service Authority
Firm Number: 300031



Gothic Insurance Brokers Ltd. is registered in England. Company Reg. Number 880423. Registered Office: Gothic House, Station Rd, Old Harlow, Essex CM17 0AP

Copyright © 2011 Gothic Insurance Brokers Ltd.