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JUKES INSURANCE BROKERS
63 Broad St., Bromsgrove, Worcestershire, UK, B61 8LL
Tel: 01527 874 092 / 575 175
Fax: 01527 575 307
Quotation Request:
Home / House Insurance
               
   GENERAL DETAILS
Title
First-name    
Surname 
Address:
Postcode:     
(day/month/year)
Date of Birth     
Telephone:
Your e-mail address
Employment Status
 
ABOUT YOUR PROPERTY
Address (if different from above)
Please indicate the number of bedrooms:
Please indicate the type of property:       
Please advise the approximate year built (e.g. 1960)
Construction
Roof
If an alarm is fitted, please indicate the type:
Buildings
sum insured: £
 (rebuilding cost)
standard
accidental damage
Contents
sum insured: £
 (replacement cost)

standard
accidental damage
All Risks Items    £
 
OTHER INFORMATION
 
Name of Current Insurer:
Please give details of any Home Insurance Claims
Current No Claim Bonus please insert either the % or number of years:
%  or years
Quotation for 12 months based on cover starting:
Please indicate where you heard about Jukes Insurance