All material facts known to you must be disclosed. A material fact is one which is likely to, influence an insurer in the assessment and acceptance of the proposal. Should you have any doubt as to whether a fact is material it should be disclosed for your own protection as failure to disclose such facts will invalidate the policy. You are recommended to keep your own record (including copies of letters) of all information supplied to us in arranging this insurance. A copy of your completed proposal form is also a proposal and policy schedule.

1. Proposer's Full Name & Trading Title      

2. Insured's Business Address                                                                                                

                                                Post Code   

    Telephone No.  :                   Mobile No.  :              E-mail  :    

3. Correspondance Address if different                                                                                                

                                                Post Code   

    Telephone No.  :                   Mobile No.  :              E-mail  :    

4.  Number of year's in business  

5.  Trade or business carried out in premises (full desciption)  

6.  Are the premises : (Please select where applicable)    Please Select A Shop A Office A Commercial/Industrial Religious Organisations Public House Restaurant/Takeaway Guesthouse/(DSS/Nursing Homes) Nightclub

7.  Are they :    Please Select Detached Semi Detached Terraced

8.  Do you occupy the entire premises ?      Please Select Yes No

     And do you live on      Please Select Yes No

     If you answered   'No' to either please complete in detail the occupancy of the premises

     Basement                          First                             Second      

     Ground                Others  

9.  State Construction of (a) External Walls of the building                                 (a) Roof    

10. Approx. age of building   

       Is any portion of the premises roof flat covered in asphalt ?      Please Select Yes No                               If Yes,         %

       Are your Premises situated with a street level CCTV area ?       Please Select Yes No

SECTION 1 - Buildings - Optional section if required

1.    Do you require cover for Buildings ?     Please Select Yes No       If Yes ...

       (a)   State the Sum Insured being the estimated cost of rebuilding                                                                                                            £  

       (b)   Loss of rent per annum     Please Select Yes No                                                                                                                                 £  

        If  'YES' please advise 12 months rent/24 months rent/36 months rent    

       (c)   Do you require Accidental Damage cover on your Buildings ?     Please Select Yes No

       (d)   Do you require subsidence cover ?     Please Select Yes No

2.     Bank/Building Society Interest to be noted in the policy     Please Select Yes No

          If  'YES' please advise    

SECTION 2 - All Risks - Optional section if required

        Specified the items to be insured :     Please Select Yes No

        Items                                                              Description                                                                                Sum Insured                       Total

        1                                         £     

        2                                         £     

        3                                         £     

        4                                         £     

NOTE : This section is designed to cover items such as scales, cash registers, typewriters, calculators, mini-computers, photocopiers, telephone installations and vending machines.

SECTION 3 - Contents/Material Damage

1. Please state your Sums insured to each of the following :                                                                                                                                   Sum Insured

    (a)   Stock excluding (wine, spirit & tobacco)                                                                                                                                         £  

    (b)   Stock of wine, spirit & tobacco                                                                                                                                                      £  

    (c)   Phone, Lottery ticket & scratch cards                                                                                                                                             £  

    (d)   Computers, Mobile phone etc.                                                                                                                                                        £  

    (e)   Internal decoration & tenants improvements                                                                                                                                     £  

    (f)   Trade furniture fixture & fittings including machinery                                                                                                                        £  

    (g)   Neon or illuminated signs/canopies                                                                                                                                                   £  

2.  The Sum Insured - Section 3                                                                                                                                                                 £  

3.   Do you keep all the content/stock on the pallet 6" above the Basement/floor level ?   Please Select Yes No

4.   Is Accidental damage cover required on all your contents ?   Please Select Yes No

Please state in space provided the two months for which stock in trade seasonal increase is to apply

SECTION 4 - Glass

Cover is automatically provided for £2000, for Shop, Office, Restaurant/Takeaway if more please advise                                                           £  

SECTION 5 - Business Interruption

Cover is automatically provided for up to twice the sum isnured under (Shop, Office, Restaurant/Takeaway) unless you request otherwise           £  

SECTION 6 - Money

1.   Do you wish to vary the standard limits in respect of either of the under mentioned limits ?   Please Select Yes No

      If   'YES' please state your requirements :

      (a)   Loss of Money from locked safe(s) when the Premises are closed for business.                                                         £2000               £  

       If you required more than £2000, please give details of your safe(s)                    Make                           Model  

SECTION 7 - Personal Accident and Assault

Cover is automatically provided as stated (for Shops, Offices, Restaurants/Takeaways only)

SECTION 8 - Goods in Transit

Automatically £2000 provided for (Shops, Offices, Restaurant/Takeaways) unless you advice otherwise.

If   'YES',  please complete the following :

      (a)   Sum Insured per Vehicle                                                                                                                                                              £  

      (b)   Number of Vehicles  

      (c)   Is cover required for goods in vehicles unattended at night ?    Please Select Yes No

If   'YES',  please give details of overnight security of vehicles :

SECTION 9 - Frozen Food - Optional section if required

1.          Do you require cover for deterioration of Frozen Food ?    Please Select Yes No

If   'YES',  please complete the following :

      (a)   Number of cabinets  

      (b)   State Total Sum Insured required                                                                                                                                                   £  

It is condition that any FRIDGE/D-FREEZER must be under maintenance contract.

SECTION 10 - Failure of Extractor Unit - Optional section if required

NOTE :

(i)   Limit any loss £350 covering a maximum closure of 48 consecutive hours

(ii)  Limited to a maximum of £1,000 any one period of insurance of not less than 12 months

(iii) The extractor unit must be the subject of a manufacturer's gurantee or warranty or subject of a maintenance and service agreement in force with a competent engineer.

SECTION 11 - Loss of Licence - Optional section if required

Do you require cover for the Loss of Licence ?    Please Select Yes No

If   'YES',  please indicate sum insured required and answer question below :

(a)   Within the last 10 years, has there been any opposition to the grant, renewal or transfer of the Licence or any circumtances or incidents likely to prevent its

         renewal ?    Please Select Yes No

If   'YES',  please give details

SECTION 12 - Liability Insurance

Cover automatically provided for (Shops, Offices, Restaurants & Takeaways) otherwise

1.   Public Liability Limited    Please Select £1M £2M

For Products Liability please provide Turnover                                                                                                                                             £  

Employers Liability. please provide Wage Roll - Clerical  £                                                                      Manual        £  

General Questions - (To be completed by all proposers)

1.   Are you currently insured or have previously held insurance against any of the risks proposed ?    Please Select Yes No

2.   If  'YES',   please state the name of insurer    

      Expiry/Renewal Date      (dd-mm-yyyy)                                                                       Policy No.    

      From which date do you wish this insurance to commence ?       (dd-mm-yyyy)

3.   Are all your existing doors of sound construction and fitted with good quality deadlocks which comply with BS362   1980

      (look for British Standard Kitemark) ?    Please Select Yes No

4.   Are all opening windows fitted with key operated window locks in addition to the standard fastening ?    Please Select Yes No

If the answer to either 3 or 4 is   'NO',  please describe

SECURITY & PROTECTIONS

A.   Fire

       Are the premises fitted with a fire alarm ?    Please Select Yes No

       Sprinkles ?    Please Select Yes No

       Fire Extinguishers ?    Please Select Yes No

       No. of Extinguishers ?    Please Select Yes No

If   'YES',  please give details

        Please state type of heating in the premises    

        Are any processes involving the application of heat carried out ?    Please Select Yes No

If   'YES',  please give details

B.   Theft

       (a)   Please give full details of protection including types of locks etc of : -

       (i)    Each outer door    

       (ii)       Doors and other access points to your parts of the building if you are not the sole occupier    

       (iii)  Cellar flaps or other basement entries    

       (iv)  Show windows    

       (v)   All other windows    

       (vi)  All skylights, fanlights or roof openings    

5.     (a)  Do you have any form of intruder alarm fitted and in working order ?    Please Select Yes No

        (b)  If an alarm is fitted is the installer a member of  N.A.C.O.S.S. ?    Please Select Yes No    Please Select Bell only Centre Station Redcare

        (c)  Is there a maintenance contract in force ?    Please Select Yes No

6.     (a)  Are the Premises in an area affected by flooding ?    Please Select Yes No

7.     (a)  Do you use a deep fat frying Range ?    Please Select Yes No

         If   'YES',  is the Range

         (a)  fitted with a thermostat which will prevent the temperature of fat or oil exceeding  205^oC  (401^oF) ?    Please Select Yes No

         (b)  additional to above, is each pan fitted with a second high limit thermostat ?    Please Select Yes No

         (c)  provided with metal lids or shutters for immediate use in event of fire ?    Please Select Yes No

         (d)  provided with a flame failure mechanism which in event of pilot light failire will cut off fuel supply ?    Please Select Yes No

         (e)  fitted with a sump which is cleared at least monthly ?    Please Select Yes No

         (f)  serviced at least once each year by trained personnel in accordance with manufacturers instruction and a service record maintained

               for inspection ?    Please Select Yes No

8.       Do you comply with the following ?

         (a)  inspect and clean at least once each month all exhaust hoods, ducting, flues and grease traps ?    Please Select Yes No

         (b)  at least once each year arrange for all exhaust hoods, ducting and flues to be cleaned and serviced by a professional maintenance

                company ?    Please Select Yes No

8.       Which of the following pieces of fire fighting equipment do you have ?

          (a)  Fire Blanket    Please Select Yes No

          (b)  Dry Powder extinguisher State No.    Please Select Yes No

          (c)  CO₂ extinguisher State No.    Please Select Yes No

          (d)  Foam extinguisher State No.    Please Select Yes No

          (e)  Water extinguisher State No.    Please Select Yes No

10.          Do all gas appliances used for cooking and pipework thereto meet relevant British Standards and are they maintained in a safe condition to comply with health and Safety regulation ?    Please Select Yes No

11.          In the last ten years have you or any director or partner (in this or any other name under which you may have been trading) suffered any loss or had any claims made against you in respect of any of the covers you are now applying for ?    Please Select Yes No

12.          Has any insurer declined or required special terms to insure you or any director or partner (in this or any other name under which you may have been trading) cancelled or refused to renew any insurance of a type you are now appying for ?    Please Select Yes No

13.          have you or any director or partner been declared bankrupt, been a director or any company which went into liquidation, or been convicted or arson, criminal deception, fraud, forgery, theft, robbery or handling or any crime of violence associated with these or with any other offence against property ?    Please Select Yes No

If the answer to any of the question11-13 is   'YES',  please give details

14.          EXCESS

               You are asked to bear the first £250 of each claim.

               Do you wish to increase this figure ?    Please Select Yes No

If   'YES',  indicate the Excess required                                                                                                                                                      £   

               Discounts are normally available for higher excesses. (  £500  Discount  7_1/2%   -  £750  Discount  10%  -  £1000  Discount  12_1/2%  )

The following security requirements must be met at ALL premises in order to the Theft Insurance cover to be valid.

The final exit door of the premises is fitted with a mortice deadlock which has give or more levers and/or conforms to BS362   1 : 1980 specification for theif resistant locks in conjuction with a matching boxed striking plate.

All other external doors are of solid timber construction with not more than one third of their area comprising glazed panels and that any glazed areas should be additionally protected insternally be metal mesh grills and all internal doors giving access to any part of the buildings not occupied by you for the purpose of the business are fitted with either :

(a)    A mortice deadlock which has five or more levers and/or conforms to BS3621 : 1980 sopecification for thief resistant locks in conjuction with a matching boxed

        striking plat or

(b)    two key-operated bolts for doors, one fitted approximately 30cms from the top of the door and the other 30cms from the bottom.

All ground floor and basement opening windows/skylights and other opening windows/skylights accessible from roofs, decks, balconies, fire escapes, canopies or down pipes are fitted with key-operated windows locks. This requirement does not apply to window skylights which are protected by solid steel bars, grilles, lockable gates, expanded metal or weld mesh.

Any door or window officially designated a fire exit by the fire authority is excluded from these requirements.

Each item of electronic equipment with an individual replacement value of £750.00 or greater shall be :

1.   permanently and prominently marked with the owner's name or company logo and either the postcode of the premises or a unique references as part of a current national property registration scheme.

or

1.   securely anchored to the desk work station or to the structure of the building by a hold down device approved by the Company the keys to which have been removed from the premises or contained in a securely locked safe the keys to which have been removed from the premises.

Some or all of the information which you supply to Crownsway Insurance Brokers Limited in connection with this insurance will be held Crownsway Insurance Brokers Limited on computer. Information may be passed to other insurers or any other recognised authority directly concerned with this type of insurance.

The insurance does not come into force until your proposal form has been accepted by Crownsway Insurance Brokers Limited.

CLAIMS : - It is a condition of this certificate that all the claims should be notified in writing direct to Crownsway Insurance Brokers Limited within 14 days of the circumtances giving rise to the claim. Failure to do so will absolve the underwriters of Liability.