Name*
Contact Number*
Email Address*
Property Address*
Do you require cover for Buildings?*	YesNo
If yes, please specify Rebuilding Cost
Do you require cover for Contents?*	YesNo
If yes, please specify value
Note: please specify ‘high risk’ items which are individually greater than €1,165.00 or collectively greater than €4,660.00
Do you want to extend particular items on an ‘All Risks’ basis?*	YesNo
If yes, please list individual items with respective values
Do you require cover for Money?	YesNo
Do you require cover for TV antenna or Satellite?	YesNo
Is your property rented out?	YesNo
Is your house unoccupied for more than 90 days in any one year?	YesNo
If yes, please give details:
Has any loss, damage or liability arisen in the last 5 years or has any insurer declined or terminated insurance or imposed special conditions?	YesNo
Is your car insured with Elmo (to benefit from further discounts)?	YesNo
If yes – registration number:
Are you an existing client of Elmo Insurance?	YesNo
If yes, name your contact at Elmo.