Laptop Insurance Issue Cover Request

Insurance2day Insurance Services Ltd are authorised and regulated by the Financial Services Authority and are members of:

Cover Required

Total Equipment Value	Total Annual Premium Nil policy excess (inc. IPT @ 5% and policy fees)
Up to £1,500	£95.00
£1,501 - £2,000	£120.00
£2,001 - £2,500	£145.00
£2,501 - £3,000	£170.00
Over £3,000	Please call Insurance2day on 0800 055 60 83

Name:

Address:

Postcode:

Contact Number:

E-mail Address:

LAPTOP DETAILS:

Make & Model:

Serial Number:

Value (£):

Details of Any Other Cover Required:

Please Confirm Annual Premium (£):

Method of Payment

If Other, please give details

Inception Date:

N.B. No cover is in place until payment is received and you receive written confirmation of cover.

Have there been any claims, or circumstances that may give rise to claims, such as would be covered by the proposed insurance in the past five years and are there any other material facts that may affect an insurers willingness to offer cover (if you are unsure as to whether a fact is material please disclose) ?

Any additional information/comments:

Thank you for completing your details - please press the submit button to request cover