Agent/Broker            Contact Name         Agency No.  :  

Phone          :                                     Fax :                                      Email Address   :  

Business (Full Description)                                                       Phone  

Business Address                                                               Post Code   

Corr. Address                                                                    Post Code  

Trading     Please Select Takeaway Restaurant Fish & Chips                 In Flooding Area       Please Select Yes No                    Years of Building           

Alarm      Please Select Yes No  Type     Part of Bld Unccupied   Please Select Yes No        Flat Roof  Please Select Yes No   %

Window Locks Please Select Yes No  Type    Does anyone live in the premises? 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    %

Building  [  AD   Please Select Yes No    Sub  ]     Please Select Yes No   £              GIT(Std.-£1000 for retail shop)         £    

Loss of Rent                                            £                                                    All Risks                                        £    

Stock in Trade                                         £                                                    Loss of Licence                              £    

Fixture & Fittings                                     £                                                    PA Accident & Assault                   £    

Intrl. Deco & Tenants Imprmt.                  £                                                    Failure of Extration Units                 £    

Wine & Spirit/Tobacco & Cig.                   £                                                    Employees Liability (Std.-£5M)        £    

Frozen Foods                                           £                                                     Public Liability(Std.-£1M)/POL       £    

Loss of Income ( X2 Inc. )                        £                                                     Products Liability ( Std. - £1M )     £    

Money - in Safe out of Business Hours        £                                                     Legal Expenses ( £100,000.00 ) Std. Charge - £25

Money ( Std. - £1000 for retail shop )         £                                                      Estimated Annual Wage Roll          £    

Glass ( Std. - £1000 for retail shop )           £                                                     Estimated Annual Turnover            £    

Need Terrorism     Please Select Yes No          If Yes , for ,       Please Select Building Material Damage Business Interruption

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