1. Producer Details

• Company Name: *
  
• Producer Code:
• Address: *
  
• Contact Name: *
  
• Email Address: * Confirm Email Address: *
  
• Telephone Number: *
  
• Fax Number:

2. Clients US Business Information

• Existing Chubb Policy Number(s) in the US:  
  
• Approximate Sums Insured on Existing US Policies: *
  
• Total Annual Premiums Payable to Chubb: *
  
• Has the client suffered any claims/losses in the last 5 years: * YesNo
  
• If yes, please supply date, circumstances and amount paid for each incident:
  

3. Client & European Property Information

• Client Name (in full): *
  
• Date of Birth: *
  
• Client Occupation: *
  
• Company Name:
• Risk Address (including postcode): *
  
• Approx Year Property Built: *
  
• Does the property have a history of flooding, subsidence, landslip or heave? * YesNo
  
• If yes, please provide full details:
• Has the property had any claims history? * YesNo
  
• If yes, please provide full details:
• Please supply full details of physical security at the property e.g. Key operated window locks, 5 lever mortice dead locks, CCTV, Electric gates, 24hr concierge:  
• Intruder Alarm: * Please Select No Intruder Alarm Bells Only Intruder Alarm Central Station Alarm
  
• Smoke Detection: * Please Select No Smoke Detection Battery Operated Smoke Detection Mains Wired Bells Only Smoke Detection Mains Wired Central Station Smoke Detection
  
• Main use of Property: * Please Select Main Residence Holiday Home Rented to Others
  
• If the property is a Holiday Home how often is it visited by either the client or someone on behalf of the client?
  

• Is the Property Vacant? * YesNo
  
• Is your property due to or undergoing renovation? * YesNo
  
• Has the property got a thatch roof? * YesNo
  
• Is the property of standard construction (Brick, Stone, Slate, Tile)? YesNo
  
• If no, please provide full details:

4. Coverages Required

PLEASE COMPLETE ALL SUMS INSURED IN GBP (STERLING), IF NIL PLEASE LEAVE BLANK

• Building: £
• Contents: £
• Addition & Alterations: £
• Deductible Required: *    Please Select £500 £1000 £2500 £5000 £10,000
  

TOTAL value of Unspecified ItemsTOTAL value of Specified Items

• Jewellery: £ £
• Fine Arts: £ £
• Precious Metals: £ £
• Furs: £ £
• Stamps: £ £
• Coins: £ £
• Guns: £ £

PLEASE NOTE: A single limit of £15,000 GBP applies to Unspecified Jewellery and £25,000 GBP applies to Unspecified Fine Art. Items above this value will need to be scheduled (specified) and full descriptions provided within 14 days of cover being bound.

• When is insurance required from? *    
  

5. Supporting and Background Information

• Please provide any additional comments or information e.g. copy valuation, Estate Agents Details:

• If you have any photographs or details of the property such as real estate particulars please email them to quantum@quantumplc.com

Thank You

• Thank you for completing the application form. We will contact you shortly to confirm the information provided and process your application.
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