Fax to 01268 779050

Fields marked * are required

Full name of Proposer :

(if not a Limited Company show full names of all Principals/Partners and the Trading Name).

Tel :
Fax :
*Email Address :

Address of Premises :



Postcode :

Additional Premises :

Year Established :

Description of Business (in full).

Period of Insurance :

From :

To :

Current Insurers :

Sums Insured

Buildings :
Tenants Improvements :
Non-Ferrous Stock & Precious Metals :
Finished Stock Of Computer Chips/Computer Hardware :
All Other Stock, Goods In Trust & Customers Goods :
Mobile Telephones :
Computers and Ancillary Equipment :
Moulds, Patterns, Dies, Plans & Drawings :
Lap-Top & Palm-Top Computers :
Machinery/Plant & All Other Contents :

Estimated Annual Turnover :
Clerical /Non-Manual Wages :
Manual Employees Wages for work at your own premises :
Delivery Drivers Wages :
Manual Work Away Wages from your own premises :
Please advise the Percentage of Wages involved in using Fixed Woodworking Machinery :	%

Public/Products Limit required. i.e. £1, 2 or 5 million :
Estimated Gross Profit Sum Insured :
State the Indemnity Period required. i.e. 12/18/24 months :	Months

Goods-In-Transit required :	Yes	No
State Limit required per vehicle load or consignment :
Loss Of Money required :	Yes	No
Standard Limits provided: £2000 whilst open/to/from Bank.

Construction Details

Please describe the Building.

a)	Are all walls (including framework) incombustible i.e. of brick, stone, concrete or asbestos.	Yes	No
b)	Are all roofs (including framework) incombustible i.e. of concrete or asbestos.	Yes	No
c)	Are all floors made of concrete.	Yes	No
d)	Are all the wall and roof linings and ceiling .incombustible.	Yes	No
e)	Are the buildings single storey (with no basement).	Yes	No

If the answer to any of the above is NO, please give details including percentage.

Premises

a)	Please state approximate age of the Buildings.
b)	Are the Premises:
i.	In the sole occupancy of the Proposer.	Yes	No
ii.	Detached or separated from any adjoining premises by brick or by concrete walls with no openings.	Yes	No
iii.	In a good state of repair and are the electrical and heating systems and machinery all in good order, regularly checked and professionally maintained.	Yes	No
iv.	Is there an Institute of Electrical Engineers certificate issued for these premises.	Yes	No
v.	Are the premises clean and tidy and is waste material swept up and removed from the Buildings daily.	Yes	No

If the answer to a or b above is NO, please give details.

c)	Are the premises ever left unoccupied for a period exceeding 30 days.	Yes	No
d)	Heating - are there any non-fixed or portable heating appliances or any heaters using paraffin, waste oil or LPG.	Yes	No
e)	Is smoking permitted on the premises.	Yes	No

If the answer to c, d or e above is YES, please give details.

Storage

a)	Is the floor area occupied for storage or warehousing (in any form) more than 25% of total floor area.	Yes	No
b)	Is any storage more than 5 metres in height.	Yes	No
c)	Is storage on a mezzanine or an upper floor.	Yes	No
d)	Is storage on fixed racking.	Yes	No
e)	Is storage on pallets.	Yes	No
f)	Is storage freestanding.	Yes	No
g)	Are plastic and/or wooden materials or articles flammable liquids or hazardous chemicals used, stored or manufactured.	Yes	No
h)	Are pallets or other combustible materials stored against the outside walls of the building.	Yes	No

If the answer is YES to any of the questions, please give details.

Security and Protection

a)	Are all the external door locks fitted with a 5-lever mortice deadlocks or close shackle padlocks and locking bars.	Yes	No
b)	Is there any higher than normal exposure to loss by arson, malicious damage by subsidence, flood, storm or impact.	Yes	No
c)	Are there fire extinguishers and or hose reels on the Premises.	Yes	No
d)	Are the premises protected by an approved or fully operational automatic sprinkler system.	Yes	No
e)	Are the premises protected by a burglar alarm.	Yes	No
i.	If yes, is the alarm Redcare/Paknet/Audible/ABC/Central Station.
ii.	Is it maintained by a NACOSS approved company.	Yes	No

If the answer is NO to (a) or YES to b, c or d on any of the above questions, please give details.

Fire Brigade

a)	Where is the nearest Fire Brigade to the premises.
b)	Approximately how far away is this.
c)	What is the distance between the premises and the Nearest water hydrant.	Yes	No
d)	Have you had a familiarisation visit from the Fire Brigade.	Yes	No
e)	Do your premises have a valid Fire Certificate:	Yes	No
f)	Do your premises require a valid Fire Certificate:	Yes	No

Business Interruption

a)	Are you dependent on any single UK supplier or customer for more than 30% of your annual turnover.	Yes	No
b)	Are you dependent on any overseas suppliers or customer for more than 5% of your annual turnover.	Yes	No

If the answer is YES to either questions in section 6, please give details.

Claims History

Have there been any occurrences during the past 5 years resulting in loss, destruction, damage, bodily injury or legal liability claims of the type for which insurance is required.

Yes

If YES, please give details below.

Date	Type	Details	Settled	Outstanding

Have there ever been any instances of flood or subsidence.

Yes

If the answer is YES, please give details.

Declaration

a)	Has the Proposer or any Director been involved with a company or firm that has gone into receivership.	Yes	No
b)	Has the Proposer or any Director or Partner been convicted of arson or any offence involving dishonesty.	Yes	No
c)	Has any Insurer:
	Ever declined to insure the Proposer, cancelled or refused to renew a policy or imposed special terms and conditions.	Yes	No
	or
	Asked for specific precautions which have not been carried out.	Yes	No

If the answer is YES to any of these questions, please give details.

Any other additional information


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