Agent/Broker        Contact Name      Agency No.   :  

Phone          :                            Fax :                            Email Address   : 

Risk Address                         Mobile              Post Code   

Corr. Address                        Phone              Post Code  

Trading      Please Select Takeaway Restaurant Fish & Chips         Years         In Flooding Area      Please Select Yes No             Stock in Outbuilding Cover      Please Select Yes No

Alarm Yes No Type Part of Bld Unccupied Yes No Flat Roof Yes No %       Yr. of Building

Window Locks     Please Select Yes No    Type       Ducting Annual Service  Please Select Yes No       Asbestos Yes No  %

Door Locks Please Select Yes No Type      Fire Blanket Please Select Yes No           Fire Extinguisher  Please Select Yes No  %

present 1. Thermostat 2. Metal Lids / Shutters 3. Auto Fuel Cut - Off ( Flame Faliure ) Mechanism 4. Yearly Servicing ]

Age      Year      Model  

Building (   AD-    SC-   )                         £                                                   Glass ( Std. £1000 )                         £    

Loss of Rent                                          £                                                    Goods in Transit (Std.-£ 1000)          £    

Stock in Trade                                       £                                                    All Risks                                          £    

Fixture & Fittings                                   £                                                     Loss of Licence                              £    

Intrl. Deco & Tenants Imprmt.               £                                                     PA Accident & Assault                     £    

Wine & Spirit/Tobacco & Cig.                £                                                     Failure of Extration Units                  £    

Frozen Foods                                        £                                                      Employees Liability (Std.-£5M)         £    

Loss of Income ( X2 Inc. )                    £                                                      Public Liability(Std.-£1M)/POL          £   

Money - in Safe out of Business Hours    £                                                      Products Liability ( Std. - £1M )        £   

Money ( Std. - £ 1000 )                         £                                                      Legal Expenses ( £100,000.00 ) Std. Charge - £25

Need Terrorism Cover ?                   Please Select Yes No

Renewal Premium   £               Renewal/Start Date        (dd-mm-yyyy)                 Present Insurers