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 or by contacting the FCA on 0845 606 1234.