Private Enquiry Form

Stackhouse Poland is one of the UK’s leading private client insurance brokers. We arrange specialist home and contents insurance for many thousands of private clients. However, we can provide portfolio arrangements for you if you have more complex requirements for homes, contents, fine art, holiday homes and motor cars with one insurer, one renewal date, one payment and a single client manager to look after you.

Please complete the brief form below and we will contact you to assist with your enquiry

*Title: *Name: *Last Name:

Address

Line One: Line Two: Town: Region: Postcode:

*E-mail (Please confirm you are happy for us to correspond with you by e-mail): *Telephone Number: Fax Number:

Brief description of your enquiry:

Please indicate areas of interest and relevant value where applicable:

House: Re-build value: Up To £300,000 £300,000 - £500,000 £500,000 - £1 m Over £1m General contents value: Up to £100,000 £100,000 - £250,000 £250,000 - £1m Over £1m Art/Antiques value: Up to £100,000 £100,000 - £500,000 Over £500,000 Jewellery value: Up to £25,000 £25,000 - £100,000 Over £100,000 Motor: Number of cars: Overseas/Holiday Home: Yacht: Other:

Please note that completion of this form does not commit you to any form of cover. This would only happen once we have assessed your demands and needs and quoted premiums and terms to you.

By submitting your details, you agree to the use of your personal information as set out in our privacy policy and terms of business. This includes for the purposes of administering our web site services and for fraud prevention. Your details will also be added to our mailing list if you indicate such by ticking the box below.

We do not supply your details to any third parties unless you specifically ask us to.

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Stackhouse Poland is authorised and regulated by the Financial Services Authority in respect of General Insurance business. Our firm's reference number is 309340, which can be checked by visiting the FSA website www.fsa.gov.uk/register

Stackhouse Poland © 2012. Registered in England at New House, Bedford Road, Guildford, Surrey GU1 4SJ. Company registration number 1163431.

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