House / Household

Street No:

Postal Code/Town:

Phone:

Telefax:

House      Appartement

Floor: 

Year built: 

Last revision of the water pipe system: 

Object rented      Object owned

Only for living purposes

Owners use

Partly let out

Permanently let out

Primary residence     Secondary residence    about days month

Swimmingpool:    No   Yes, inside    Yes, outside

Losses over the past 5 years
(Non-entry indicates absence of losses)
Year / Causes of Loss / Loss in EUR

Reconstruction Value of all items
forming part of the construction:

Household Insurance:

Replacement Value of all items belonging to the household:

In order to allow for greater transparency and proper coverage kindly enter the appropriate values below.
Please note: Jewellery and cash are only covered if mentioned.

Has a burglary alarm been installed?
No    Yes     Yes, being connected to:

Other security measures
(e.g. iron bars, wooden shutters, lockable windows, etc.):

Is the object being attended to during your absence (e.g. security service, housekeeper, neighbours)?

No    Yes

Is the object situated in a guarded urbanisation?

No    Yes

A deductible rate will lower the premium rate. Desired deductible?

Standard deductible 250,- EUR    500,- EUR    others EUR:

House and property liability insurance: : EUR 1.000.000,- (EUR 32,70)  
Yes    No

Personal liability insurance: EUR 1.000.000,- per family community EUR 77,00)  
Yes    No

Liability insurance for dog owners: EUR 1.000.000,- (per dog EUR 64,00)     
Yes    No