Chelmsford Insurance Centre Corporate Services Ltd

Request a quotation from Chelmsford Insurance Services, by filling in as much of the form below as possible (*your name, telephone number and email address are mandatory), and then press the Submit button.

PROPOSER
Title*		Mr Mrs Ms Dr Other
First Name*
Surname*
Address
City/Town
County
Postcode
Country
Home Telephone No.*
Work Telephone No.*
Fax No.
Mobile No.
Email Address*
Best time to contact you		As soon as possible Morning Afternoon Evening
Occupation
Date of Birth
RAILWAY MODELLER PROTECTION DETAILS
Are you a member of a Railway Club?		Yes No
If Yes, please state name of Railway Club
Are the items to be insured owned solely by yourself or by individual members of the club?
Please state total Sum Insured, and give a split between rolling stock, layout and tools:
Total Sum Insured	£
Rolling Stock	£
Layout	£
Tools	£
Are there any individual items over £1000? Please specify:
Please give a split between UK Cover and Home Cover Sum Insured (Please see notes below).
UK Cover	£
Home Cover	£
Public/Products Liability Cover at £2,000,000 required? (Please see notes below)		Yes No
Unattended vehicle cover required? (Please see notes below)		Yes No
Have you had any claims in the last five years?		Yes No
If Yes, please state brief details and costs involved
Is there any additional information that may be relevant?		Yes No
Any further relevant information
Please enter the two english words you see with a space between them. If you cannot read it then please just press the refresh button opposite.

Home Cover provides cover for items kept in the home only. No cover is provided for any losses outside of the home.

UK Cover provides cover for items kept in the home, and also extends to provide cover for items taken outside of the home. i.e. to shows, meetings etc.

Unattended Vehicle Cover provides cover for items left in a parked vehicle. A total limit of £2000 applies, and any one item valued over £100 must not be left in the vehicle.

Public/Products Liability Cover provides a limit of £2,000,000. Liability cover for you and your collection should injury/damage be caused to a third party or their property.

Please note: all personal information provided on this form will be used solely for the purposes of answering your query or providing your quote, informing you of future offers and improving our services. This information will NOT be passed to any third party.

Page last updated: 13-jun-08