INSURANCE SERVICES. FINANCIAL SERVICES. RISK MANAGEMENT
Please complete as much of the form as possible. Fields in bold (also marked with a *) are mandatory and must be completed.
* Client Name
* Trading Name
* Address
* Postcode
* Tel No
Fax
* Email
Website
Contact Name
Contact Address (if different from above)
Contact Postcode
Contact Tel No
Contact Fax
Contact Email
Contact Mobile
Trading Status
* Have you had any previous convictions, bankruptcy or insurance declined
Have you even been prosecuted or served a prohibition order by the HSE
* Occupation/Trade
* Description of work undertaken
Number of years trading
No of years experience
Which floor level does your business occupy? (e.g., ground, first floor, second floor, etc.)
* Are you the sole occupant(s) of the building in which your premises are situated?
If No, please provide details of the other types of businesses that operate from the building
* Is your office entirely self-contained with its own separate lockable entrance?
If No, please provide details
* Is the building of standard construction? (e.g., brick/stone/concrete walls & tile/slate roof)
Approximately, what year was the property built?
Has the property ever suffered from subsidence or flood damage?
If yes, please provide details. (e.g., date of damage, amount of damage, etc.)
* Are any parts of the building at present unoccupied?
If yes, please provide details
* Are all your external doors fitted with a minimum of 5 lever mortise deadlocks which comply with BS3621 (or equivalent)?
* Are all opening windows, fanlights and skylights fitted with key operated window locks?
Are all accessible windows protected by either solid steel bars or grilles?
* Are your premises protected by an annually maintained intruder alarm?
Type of intruder alarm signalling
Are the shop front windows protected by metal roller shutters?
Are your premises situated within a street level Local Authority Council CCTV area?
Do the premises have 24 hour access?
If so, is the front desk manned overnight?
Please provide details of any other security arrangements (e.g. security guarding, own internal CCTV, etc.)
Do the premises have fire extinguishers?
Do the premises have a fire alarm?
If yes, is the fire alarm manual or automatic?
Do the premises have a sprinkler system installed?
Buildings Sum Insured including outbuildings, rebuilding architects' fees, removal of debris, etc (£)
OR
Tenants Improvements Sum Insured (£)
* Computers Sum Insured (£)
* Other Electronic Equipment Sum Insured. (e.g., fax, photocopiers, telephone equipment, etc.) (£)
* All Other Contents Sum Insured. (e.g., office furniture, filing cabinets, etc.) (£)
Do you require cover for fine works of art?
If so, please provide sum insured (maximum sum insured of £5,000 for any one item) (£)
* Business Files/Documents Sum Insured (£)
* All Risks Sum Insured (i.e. property away from the office) (£)
Area of cover
Type of property to be covered away from the office. (e.g., laptops, digital cameras, etc.)
Money during business hours (£2,000 std. cover)
Money out of business hours(£)
If over £1,500 please provide make and model of safe
* Do you require Business Interruption Cover?
* Annual Gross Revenue (including payroll)(£)
Standard limit of indemnity (included in cover)
£5,000,000
Is Product Liability required?
Estimated turnover (£)
Employers liability limit of indemnity (included in cover)
£10,000,000
* Clerical/Managerial
* Manual/Facilities
Wages Estimate (£)
* Is any work undertaken away from the premises?
If yes, please provide details.
* Have you made any claims in the last 5 years?
If yes, please advise date, type of loss and settlement amount.
Date
Type of loss
Settlement Amounts (£)
If there is any other information you wish to disclose or type of cover that you require, or if you have any additional requirements please provide details.
Renewal date/cover start date
Current/Previous Insurer
Current renewal premium/best quote (£) per annum
* Signed (please type your name in full)
* Dated
