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    Please complete the form below to receive your quote. It shouldn't take you longer than 5 minutes. Have you got the time to SAVE on your insurance premium?
    Alternatively we can collect details over the phone with you.

    Contact Name*

    Company Name

    Telephone Number*

    Email Address*

    Business Address

    Town

    Postcode*

    Location of Premises*

    Business Description

    Trading Status*

    If Other, Please Detail

    Website

    Number of Years Trading in Total

    Policy Due Date

    Current Insurance Held With

    Current Insurance Premium

    Have You Had Any Claims in the Last 5 Years?*

    If Yes, Please Detail Dates, Incidents & Amounts

    Facilities Available

    Is Frying Equipment Used?*


    SUMS INSURED – IF A NEW VENTURE, PLEASE PROVIDE YOUR BEST ESTIMATES

    Buildings

    Do You Require Subsidence Cover?*

    Tenants Improvements

    Electronic Business Equipment

    Activity and Play Equipment

    Other Contents, Fixtures & Fittings

    All Other Stock

    Wines and Spirits

    Beers

    Frozen or Refrigerated Stock

    Glass

    Signs and Canopies

    Money (Business Hours)

    Money (After Hours in Safe)

    Type of Safe on Premises?*

    Goods in Transit

    Maximum Business Interruption Cover

    Business Interruption Indemnity Period*

    Loss of Rental Income

    Outstanding Debit Balances (Book Debts)

    Loss of Licence

    Public Liability Indemnity Limit*

    Your Annual Turnover

    Number of Employees

    Your Annual Staff Wageroll

    Employers Reference Number (ERN)

    Do the Premises Have an Intruder Alarm?

    Does Your Alarm Have Police Response?

    Do the Premises Have CCTV?

    Do the Premises Have a Fire Alarm?

    What Year Were the Premises Built?

    Notes, if any


    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*

    If you do not agree, please explain

    How did you hear about us?