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    CALL US NOW ON 01254 383 712


    CONTACT DETAILS

    Contact Name*

    Telephone Number (Mobile)*

    Telephone Number (Landline)*

    Email Address*

    Policy Due Date

    Current Insurance Held With

    Current insurance Premium

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

    If Yes - Please Specify Dates, Incidents and Amounts

    Insured Name

    Correspondence Address

    Town

    Postcode*


    PROPERTY DETAILS

    Property Risk Address

    Town

    Postcode

    Date Property Purchased

    Property Type*

    If Other - Please Specify

    Occupancy Trade Description

    Is the Property Occupied?*


    SUMS INSURED (REINSTATEMENT VALUES)

    Buildings

    Landlord Contents

    Glass

    Loss of Rental Income per Annum

    Loss of Rental Income Indemnity Period

    Property Owners Liability*

    Subsidence Cover Required?*

    Accidental Damage Cover Required?*

    Legal Expenses Cover Required?*

    Number of Storeys

    Are Premises All of Standard Non-Combustible Construction?*

    If 'No' - Full Construction Details

    Any Part of the Roof Flat or Felt?*

    If 'Yes' - Percentage

    Any Composite/Insulation Panels?*

    If 'Yes' - Full Panel Details

    Building Grade Listed?*

    If 'Yes' - Grade

    Premises Heated by Standard Fixed Heating?*

    If 'No' - Heating Method

    Any Adjoining Buildings/Properties?*

    If 'Yes' - Neighbouring Trades & Firewalls

    Has the Property Ever Suffered from Flooding?*


    SECURITY DETAILS (UNDER YOUR CONTROL)

    Does the Property Have an Intruder Alarm?*

    Is Your Alarm Annually Maintained under Contract by a NSI(NACOSS)/SSAIB accredited Firm?*

    Does Your Alarm Have Police Response?*

    Does the Premises Have CCTV?*

    Roller Shutters/Grills to Doors/Windows?*

    24-Hour Onsite Security?*

    Fire Alarm (Integrated Mains Wired Alarm)?*

    Is Your Fire Alarm Connected to a Central Station or the Fire Brigade?*

    Sprinkler System?*

    Additional Notes


    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?