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Full name:

Address:

Email:

Contact number:

Date of birth:

Occupation:

Type of property (if flat please state which floor):

Number of bedrooms:

Year of build:

List of items and values:

Is there a safe installed at the home? (if so please provide make, model and cash rating)

Please advise if any additional security at the home:

Any previous claims:

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If you'd like to speak to one of our team members directly, call us on +44(0) 20 7031 2767 or email privateclients@miller-insurance.com