To obtain a quotation simply complete the form further down this page and click send. If you prefer you can Click here to open a “printer friendly” version.

You can send your printer friendly version back to us in 3 ways:

  • Fax it to us at 01902 710327
  • Post it to us at FREEPOST RRRT-KHXA-BUHT, CHU, 29 Waterloo Road, WOLVERHAMPTON, WV1 4DJ.
  • Scan and Email it to us at
Company Name:
Your Name:
Postal Address:
Tel No:
Where did you hear about us?
Renewal Date:
Current Insurer:
Current Premium
Address of Property to be insured:
Description of Property to be insured
Sum Insured:
and (if shown) Declared Value.
No. of buildings:
Age of Property:
No. of flats/residential units:
if converted, when?
No. of storeys:
Does the Property have any flat roofed areas?  Yes No
If yes, when were the covering materials used for the flat roofing last renewed or replaced?
Floors & Stairs:
No. of garages :
Are they in a separate block? Yes No 
Is the Property to be insured listed?

Additional Information
1. Number of Residential Units/Flats which are:

Owner Occupied:
Let under assured short hold tenancy agreement or similar:
Let under other conditions
Additional Comments:
2. Is any part of the property occupied by or let as:
Holiday Homes/Second Homes   Yes No
Bedsits  Yes No
Student Accommodation             Yes No
DSS Tenants  Yes No
Hostels/Homes Used By Local Government or Charitable Organisations   Yes No
If Yes, Number of Flats/Residential Units
3. Is the property in a good state of repair?   
 Yes No
4. Is your property currently, or has it ever been affected by subsidence, ground heave, landslip, storm or flood?     
 Yes No
5. Is the property currently undergoing renovation, repair conversion, or alteration or is any such work anticipated in the next 12 months?
 Yes No
6. Are there any communal facilities? (lift, boiler, tennis courts, swimming pool etc)
 Yes No
7. Is there any commercial use? (i.e. shops, offices, restaurants)
 Yes No
If the answer to Questions 3,4,5,6 or 7 is “Yes” – Please provide additional details:
8. Are there any trees within 10metres of the property?
 Yes No
9. Are there any bushes/shrubs in excess of 3m in Height within 10metres of the property?
 Yes No
If you have answered “Yes” to Questions 8 or 9:
Is there an ongoing programme of pruning/pollarding/thinning out or crown reduction for trees/bushes/shrubs at least every 3 years?
 Yes No
10. Do you use the services of a Property Management Company?
 Yes No
11. Are the Communal Areas protected by automatic fire alarms/heat sensors/smoke detectors?
 Yes No
12. Does the property have access control features such as CCTV, Telephone Entry Systems, Manned Lobby Area, Concierge or Restricted Access to Owners/Tenants only?
 Yes No
13. Has IEE/ITC wiring certification or similar for the common areas been issued within the last 3 years?
 Yes No
14. Is there a fire risk assessment for the Property?
 Yes No
15. Have you or any officers, directors or partners:
i) ever been refused insurance or had special terms or conditions imposed?
 Yes No
If yes, please provide additional information below:
ii) ever been convicted or cautioned for any criminal offence (other than minor motoring offences)
 Yes No
If yes, please provide additional information below:
iii) ever been declared bankrupt or insolvent, been the subject of a county court judgement, an involuntary arrangement or a sheriff court decree?
 Yes No
If yes, please provide additional information below:
16. Have you sustained any losses involving the risks proposed, or had any claim in the last 3 years?
 Yes No
If yes, please provide additional information below:
Additional Covers:

The CHUResidentsline policy automatically provides a comprehensive package of cover including “all risks” cover for buildings, public liability, employer’s liability and optional legal expenses. Please indicate if you would be interested in options to include cover for:
 Yes No
Directors and Officers Liability:
 Yes No
Directors and Officers Liability - if yes select limit below
 £100,000 £250,000 £500,000 £1,000,000 £2,000,000
Lift Inspection and Machinery Breakdown Insurance:
 Yes No
If Yes, Please confirm number of lifts per building and number of floors
Fidelity Guarantee: (This covers you against fraudulent misappropriation of your money)
 Yes No
Personal Accident Cover for Voluntary Workers:
 Yes No