Broker Name:

Address:

Town/City:

County:

Postcode:

Tel Number:

Facsimile:

Email:

Client Name:

Address:

Town/City:

County:

Postcode:

Type of Business:

Insurance Type: liability shops & offices property owners miscellaneous

Full Business Description:

How Long Established:

Types of Premises Work On:

Is there any height work: Yes No

Please provide details:

Is there any heat work: Yes No

Please provide details:

Is there any depth work: Yes No

Please provide details:

Employers Liability Required: Yes No

If YES, Estimated wages for the period of insurance proposed for the following catagories:

Public Liability Required: Yes No

If YES, Limit of Indemnity required: £1m £2m £5m £10m

Estimated turnover for the period of insurance proposed, split by territory (£'s):

Product Liability Required: Yes No

If YES, What is the Percentage split by territory from where the Proposer's products are delivered?:

Full Business Description:

How Long Established:

Is Accidental Damage required: Yes No

Is Subsidence cover required: Yes No

Buildings Sum Insured:

Tenants Improvements Sum Insured:

Shopfront Sum Insured (max £25,000):

Rent Payable Limit (max £75,000):

Indemnity Period: 12 months 24 months

Total of High Risk Stock (max £50,000):

All other Stock Sum Insured:

All other Contents Sum Insured:

Total of UK All Risks (max £10,000):

Frozen Food Limit:

Goods in Transit Limit (max £10,000):

Money in Transit Limit:

Is more thatn £2000 kept in a safe: Yes No

If YES, Please advise make & model of safe and amount held in safe:

Public Liability Limit required: £2m £5m

Is the premises occupied overnight by the Policyholder or employees: yes no

Is there a NACOSS/SAIB intruder alarm fitted to the premises: yes no

If YES, Please give full details on system:

Is the premise fitted with metal shutters or steel lined doors and grills: yes no

Loss of Licence Limit Required(min £10,000 and max £100,000):

Are there any interested parties associated wtih this risk: yes no

Full Risk Address:

Basis of Cover: All Risks Fire and Special Perils

Limit of Indemnity for Property Owners Liability: £1m £2m £5m

Employer Liability Required: Yes No

If Employers Liability is required please advise type of employee(s):

Limit of Indemnity for Property Owners Liability: Flats (converted) Flats (purpose built) House Individual Flat Industrial Unit Office Offices with flat above Retail Warehouse Shop Shopping Centre Shops with flat above Surgery Surgery with flats above Warehouse

What year were the premisies built:

Please enter the number of storeys:

Please advise the type of residential occupant, if any:

Please advise the type of commercial occupant, if any:

If any parts of the premises are unoccupied please enter the proportion (%) that is unoccupied:

Is Subsidence cover required: Yes No

Has the property or adjacent property suffered any obvious damage from subsidence or show any visible signs of cracking: Yes No

Is the property in an area with a history of flooding: Yes No

Please enter the year the premises were purchased:

Please enter the Buildings sum to be insured:

Please enter the Rent sum insured:

Please enter the indemnity period required for Rent: 12 months 24 months 36 months

Please supply a free format presentation in the box provided:

Claims History:

Notes:

Current Insurer:

Renewal Date:

Target Premium:

Excess:

Any Terms: