Holiday Home Insurance Step 1 of 3 33% First Proposer Name First Last Date Of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Second Proposer Name First Last Date Of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Address To Be Insured Street Address Address Line 2 City State / Province / Region ZIP / Postal Code IrelandAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do You Have a Working House Alarm? Yes No Type Of PropertyDetached HouseSemi-Detached HouseBungalowTerraced HousePurpose Built ApartmentFlat/MaisonetteBedsitCountry MansionDate of Construction/Build MM DD YYYY Number Of Claims Free YearsWhat Cover do You Require? 1. Buildings - Rebuilding cost of the property (including garages, domestic outbuildings etc. and associated fees for eg. Architects fees) 2. Contents - Replacement cost of your contents (note contents in garages and domestic outbuildings are covered up to a limit of €1,000) Please note that a quotation will be provided to you on the basis that you have confirmed the following statements to be true: The property is not a rented Holiday Home and is used only for recreational purposes. The property, including domestic outbuildings, is in a good state of repair and will be maintained in a good state of repair at all times and are free from any signs of external or internal cracks other than fine surface cracks in plaster. The property, including domestic outbuildings: Does not have any trade, profession or business being carried out. Is not used to store commercial goods, for example, stock. Is not used as the place of employment for any employee other than Domestic Employees. The property, including domestic outbuildings: Shows no sign of damage which may be attributable to subsidence, heave or landslip. Has never been monitored for subsidence heave or landslip. Has never been subject to a survey which mentions settlement or movement of the property. Has never been underpinned. Is not within 200 metres of any property that has been subject to subsidence, heave, landslip, coastal or river erosion. The property, including domestic outbuildings: Has never suffered damage due to flooding. Is not within 100 metres of any property or development which has been subject to flooding. Is not within 100 metres of any lake, river, stream, canal, sea, or any other body of water. The property is constructed of brick, stone or concrete, including timber frame with concrete or brick external cladding. The property is roofed with slates, tiles, concrete, metal (other than corrugated iron), asphalt, mineral felt or torch on felt. Where any portion of the roof is covered with mineral felt or torch-on felt, it is no greater than 50% of the total roof area. The property is not currently under construction, renovation, extension, repair or redecoration (excluding minor internal decoration work such as painting and wallpapering). The proposer for this insurance is an individual and not a company or firm. The property is not subdivided, for example into flats or bedsits. The property is not a thatched property, country mansion, wind and water mill or working farm. The property is not a listed building or subject to a preservation order. The property is not left unoccupied for more than 45 consecutive days. All person(s) with an insurable interest in this property have been listed on this form. The land belonging to the property does not exceed more than 1 acre All external doors are fitted with Five-Lever mortice deadlocks and all accessible windows, excluding bedroom windows, are fitted with button operated window locks You or any member of your household or anyone who occupies the property have not ever suffered any loss/losses relating to water damage, liability, subsidence and /or flood You or any member of your household or anyone who occupies the property, in the last five years have: Not made more than one household insurance claim (whether the claim was covered by the policy or not). Not made a claim totalling more than €15,000. No open claim(s). You or any member of your household or anyone who occupies the property have never been convicted of, or have any prosecutions pending, for any offence (other than speeding or parking offences). You or any member of your household have never been refused insurance or had insurance cancelled or special terms or conditions imposed by any insurer (for example, increased excesses or policy loadings). I confirm that the information provided by me has been gathered for the purpose of obtaining an insurance quotation. I am aware that by providing such information this does not confirm that a quotation can be offered to me nor does it confirm that an insurance policy is in force.