Full name:	*
Address:
Post code:	* (Location of risk to be insured)
City:
Telephone:	*
Fax:
E-mail:
The insured risk to be considered is           Main home           Second home *
Ground floor Flat not on the ground floor one-family semi-detached or terraced house One-family detached house or bungalow
Year of construction / rebuild *
Surface construction	m2 *
Location of the risk: *
In town/urban centre In residential area  In rural area (to +1 km. of the urban centre)
Security:
Glass panes only  Metal bars in all openings Shutters or blinds of wood or aluminium in all openings Other
Alarm:                                                         YES        NO *
Alarm connected to a Security Centre:           YES        NO
Capitals to insure
Building:	€ The structure, and walls, gates, fences, central heating, air conditioning, kitchen furniture, parquet flooring etc. and in general all elements in connection with the building (sun blinds, awnings, terrace enclosures, etc.).
Building alterations:	€ (improvements incorporated such as air conditioning, gates, sun blinds, terrace enclosures etc.)
Value of swimming pool:	€
Contents composed of:
Furniture/household effects/personal possessions:	€
Jewellery:	€
Objects of value/valuables	€ Pictures, objects of art, antique objects, furs, collections, other objects of special value.
I would like to receive the information by:
E-mail Fax Telephone Mail A personal visit from the Broker           In person in Duñach's office in Roses  In person in Duñach's office in Empuriabrava