Main Details
  Title:  *
  First Name(s):  *
  Surname:  *
  Please enter your postcode and press the 'Look Up' button *
  Contact Phone Number: *
  Email Address:  *
  Date Of Birth:  *  (DD/MM/YYYY)
  Marital Status:  *
  Main Occupation *
  Employer's Business  *
  What is your current employment status? *
  On what date do you require the cover to commence? *  (DD/MM/YYYY)
  Would you like buildings cover only, contents cover only, or both?  *
Property Details
  Property Type:  *
  Number of Floors:  *
  Number of Bedrooms:  *
  Year Bulit:  *
  Construction of Walls:  *
  Construction of Roof:  *
If a security system is fitted, what type is it?  *
 
Contents Cover
  How long have you held contents insurance without claiming?  *
  What amount of contents cover do you require?  *
  Do you require cover for Personal Possessions taken out of the home?  *
  Do you wish to include cover for specified items?  *
 
Buildings Cover
  How long have you held buildings insurance without claiming?  *
  What amount of buildings cover do you require?  *
 
  * These questions must be answered
 
Copyright Jukes Insurance 2008 | Registered Office 63 Broad Street, Bromsgrove | Worcestershire | B61 8LL.We are an independent intermediary authorised and regulated by the
Financial Conduct Authority. Our FCA registration number is 305796. You can check this by visiting www.fsa.gov.uk/register or by contacting the FCA on 0845 606 1234.