Business Insurance Enquiry Form
 
 
General Questions
 Name:
 Company Name(if different):
 Business:
 Address:
 Phone:
 Email:
Current Insurance Details
 Current Insurer:
 Renewal Date:
 Number of Years in Business:
Claims History
 Are there any Claims within the past 5 Years: YesNo
Type of Claim Date of Claim Amount of Claim Paid / Outstanding Comments
Property Cover
Please tick type of cover required :
Accidental Damage including Subsidence
Accidental Damage excluding Subsidence
Fire/perils only
 Is theft cover required: YesNo
Sums Insured
 Building :  
 General Contents (Excluding Computers) :  
 Stock :  
 Tenants Improvements :  
 Tobacco & Equipment :  
 Photographic Equipment :  
 Deeds, Documents & Transparencies :  
Specified Items (Please detail any items to be used away from premises)
Description (Make/Model) Sum Insured
Is the building of standard construction(constructed of non-combustible materials) YesNo
Please tick if any of the following are in the premises
Fire Extinguishers
Hose Reels
Fire Alarm
Sprinkler System
Is there an intruder Alarm connected to a Central Station YesNo
Does Owner or Staff Member live on premises? YesNo
Is the Shop an internal unit in a shopping centre YesNo
Business Interruption
 Gross Revenue :  
 Additional Cost of Working :  
 Indemnity period :
12 months 18 months 24 months 36 months
Employers Liability 13,000,000 Limit of Indemnity
Description (Make/Model) Estimated Wages
 Clerical
 Property Repairers
 Other
Does the Wageroll exceed 500,000 YesNo
if yes state Wageroll
Public Liability cover
1,300,000 2,600,000 6,500,000
 Basis of Cover Public Liability onlyPublic/Products Liability
 If Public/Products Liability cover is required please complete the following
 Description of Turnover  Estimated Wages
If Wholesale
Wholesale YesNo
Are any products sourced outside the EU YesNo
Have any rights of recovery been waived in respect of these products YesNo
Are any of your products exported to the USA or Canada YesNo
If Club
Club YesNo
Is member to member Liability cover required YesNo
If Manufacturing
Manufacturing YesNo
Will any of the products have an end use in Automotive, Aeronautical or Medical Industries YesNo
If Hairdresser/Barber
Hairdresser/Barber YesNo
Number of Qualified Stylists
Money Cover
In Premises/Transit/Bank Night Safe(Standard 10,000) Required  
Money in unspecified safe ( Standard 2,500) Required