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Contact Name:

Company Name:

Telephone Number:

Email Address:

Business Address:

Town:

Postcode (required):

Location of Premises:
—Please choose an option—Business Park UnitIndustrial UnitUnit Within Indoor shopping CentreSelf Contained Premises Within Multi Tenure MillResidential StreetsideHigh StreetIndoor leisure complex

Business Description:

Trading Status:
—Please choose an option—Limited CompanyPartnershipSole Trader Trading asOther

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?:
—Please choose an option—YESNO

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

Facilities Available:

Is Frying Equipment Used?:
—Please choose an option—YESNO

Sums Insured - If a new venture, please provide your best estimates

Buildings:

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

Tenants Improvements:

Computers, Cash Registers and Other Electronic Business Equipment:

All Activity and Play Equipment:

All Other Contents Fixtures and Fittings:

All Other Stock:

Wines and Spirits:

Beers:

Frozen Or Refrigerated Stock:

Sum Insured For Glass:

Sum Insured For Signs And Canopies:

Money Cover In Transit and On The Premises During Business Hours:

Money Cover After Business Hours In a Locked Safe:

Type Of Safe On The Premises?:
—Please choose an option—No Safe on PremisesSafe Installed and Operated in line with Manufacturers Instructions & Cash Rating For The Amount of Money to be Stored Within

Sum Insured For Goods In Transit:

Maximum Business Interruption Cover Required:

Maximum Business Interruption Indemnity Period Required?:
—Please choose an option—12 Months18 Months24 Months36 Months

Loss Of Rental Income:

Outstanding Debit Balances Book Debts:

Loss Of License:

Public Liability Indemnity Limit?:
—Please choose an option—£1,000,000£2,000,000£5,000,000£10,000,000

Your Annual Turnover:

Number Of Employees:

Your Annual Staff Wageroll:

Your Employers Reference Number ERN:

Do The Premises Have An Intruder Alarm?:
—Please choose an option—NOYES - Bells / Audible OnlyYES - Digital Communicator Keyholder AlertYES - Central Station Monitored

Does Your Alarm Have Police Response?:
—Please choose an option—NOYES - Level 1YES - Level 2YES - Level 3

Do The Premises Have CCTV?:
—Please choose an option—YESNO

Do The Premises Have A Fire Alarm?:
—Please choose an option—YESNO

What Year Were The Premises Built?:
—Please choose an option—Pre 18511851 - 19201921 - 19391940 - 19791980 - 19891990 - 19992000 & later

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(*)?:
—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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