HOME INSURANCE          APPLICATION FORM

   GENERAL INFORMATION

   APPLICANT / POLICY HOLDER                 (all information is required)

PASSPORT/NIE

NAME  / SURNAME 

BIRTHDAY 

ADDRESS 

  POSTCODE    /  CITY 

 COUNTRY

  EMAIL ADDRESS

 TELEPHONE

   SPANISH BANK ACCOUNT

  SAVING BANK (20 DIGITS)

   RISK SITUATION HOME (IN SPAIN)

ADDRESS

  POSTCODE   /  CITY

 REGION

   HOME INFORMATION

   PROPERTY TO BE INSURED

METRES

APARTMENT 

DETACHED

USAGE

  -Selection- YES NO

-Selection- YES NO

-Selection- PERMANENT HOME SECOND HOME

   PROPERTY DETAILS / CHARACTERISTICS

BUILDING YEAR

WOODEN STRUCTURE

DOGS IN THE

PROPERTY

 LOCATION

-Selection- YES NO

-Selection- TOWN URBANISATION RURAL UNINHABITED

SECURITY DOORS

WINDOW BARS/GRILLS

ALARM

IF YES, ALARM CONNECTED TO A RESPONSE CENTER

-Selection- YES NO

-Selection- YES NO  

-Selection- YES NO

   CAPITAL TO BE ASSURED

   GIVE DETAILS ABOUT THE VALUES TO BE INSURED

CAR IN THE GARAGE

IF YES PLEASE SPECIFY 

MODEL,  VALUE AND REGISTRATION Nº

-Selection- YES NO

BUILDING COVER REQUIRED 

CONTENS COVER REQUIRED 

ANY ITEMS OTHER THAN STANDARD HOUSE CONTENTS SUCH AS JEWELLERY, PHOTOGRAPHIC/SPORT EQUPMETN WITH A VALUE OF MORE THAN E600 SHOULD BE INSURED SEPARATELY. PLEASE, SPECIFY UNDER "COMMENTS" AND WE WILL ARRANGE A SEPARATE QUOTATION.

   COMMENTS

ADD HERE ANY RELEVANT INFORMATION THAT MUST BE TAKEN INTO ACCOUNT FOR TAKING YOUR HOME INSURANCE POLICY ON

Do you declare that all the answers given in this application form are true?  --- YES