Please complete the form below to receive your quote.
Alternatively we can collect details over the phone with you.
Please leave this field empty.
Your Name:

Telephone Number:

Email Address:

Correspondence Address:

Postcode:

Policy Due Date:

Name of Insured:

Address of Plot of Land:

Postcode of Land:

Type of Land:
—Please choose an option—Grazing landMoorlandWoodlandPasture landRough countryPrivate roadDevelopment siteSelf buildOther

Size of Land (in acres):
—Please choose an option—up to 1 acreup to 2 acresup to 5 acresup to 10 acresup to 15 acresup to 20 acresup to 30 acresup to 40 acresup to 45 acresover 45 acres

Level of Public Liability Indemnity Required:
—Please choose an option—£1 million£2 million£5 million£10 millionOther

If you have selected 'Private Road' as type of land, is the Private Road/Residents Land in a good state of repair and regularly maintained?:
—Please choose an option—YESNONot Applicable

If the land is let out to a third party to use as farm land, do they have their own farming insurance policy in place?:
—Please choose an option—YESNONot Applicable

Is the land being used for growing crops for a commercial benefit?:
—Please choose an option—YESNO

Does the insured allow neighbours to use the land to let their animals graze?:
—Please choose an option—YESNO

Are there any watercourses or significant water features within the land to be insured or adjacent?:
—Please choose an option—YESNO

Is or was the land to be insured used or ever used, by any petrol station, chemical works, gas works, oil refineries, power stations, underground mines or any other industries of this nature?:
—Please choose an option—YESNO

If Yes, Please provide further details here:

Are there any buildings/ structures situated on the land?:
—Please choose an option—YESNO

If 'Yes

Is the land owners liability to extend to these buildings?:
—Please choose an option—YESNONot Applicable

Are these buildings occupied or unoccupied?:
—Please choose an option—OCCUPIEDUNOCCUPIEDNot Applicable

If these buildings are unoccupied are they structurally sound, secure and not accessible or open to the public?:
—Please choose an option—YESNONot applicable

Is material damage cover required for the buildings?:
—Please choose an option—YESNONot Applicable

If 'Yes

Buildings reinstatement value:

Do You Require Subsidence Cover?:
—Please choose an option—YESNONot Applicable

Current Insurance Held With:

Current Insurance Premium:

Have you had any claims in the last 5 years?:
—Please choose an option—YESNO

If Yes Please Specifically Detail Dates, Incidents And Amounts Here:

Additional Information

Any further information or material facts you should or would like us to advise underwriters

Declaration
You or any director or partner in any business, any partner in any partnership, any director of any company, or the company;
either in any personal capacity, in the name of the business proposed or in respect of any other business in which any of you have ever had an interest have:

- Never had a proposal for insurance declined, cancelled or refused?
- Never had insurance cancelled mid-term, a renewal refused, increased or special terms or conditions imposed by an insurer?
- Never been given an official police caution, convicted of, charged (but not yet tried) or have any prosecution pending for any offence (excluding any motoring convictions and any offences which are spent under the Rehabilitation of Offenders Act 1974)?
- Never been the subject of or issued with a County Court Judgement (CCJ), money judgement or court decree and/or ever been cited in any unsatisfied court judgements (or the Scottish equivalent) or any other judgements or decrees in relation to debt?
- Never been declared bankrupt or insolvent, the subject of an individual voluntary arrangement (IVA) or company voluntary arrangement (CVA) with creditors, voluntary liquidation, a winding up or administration order, or administrative receivership proceedings, bankruptcy or insolvency proceedings?
- Never been disqualified from being a company director?
- Never been censured by any regulatory or trade body or any action been taken against the company by the office of fair trading, consumer groups or the alike?
- Never been served under any Health & Safety, Welfare, Environmental, Consumer Protection or Food Safety legislation or any other legislation, with any warnings, enforcement measures, prohibition notice, improvement orders, proceedings or criminal proceedings by any Health and Safety Executive, Environmental Health Office, Environment Agency, local or government authority or any other enforcement agency or authority?
- Never been convicted of, charged (but not yet tried) with, officially cautioned or have any prosecution pending for a breach of any Health & Safety, Welfare, Environmental, Consumer Protection, Food Safety legislation or any other legislation?
- Never been the subject of a recovery action by Customs and Excise or the Inland Revenue?

Please Confirm If You Agree With The Declaration(*)?:
—Please choose an option—NO - I Do Not AgreeYES - I Agree

IF You Do Not Agree With The Declaration Please Advise Why Here:

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