1. Disclosure

a. Has the proposer, any Director or Manager of the Proposer (if a company), or any partner (if a firm);

i. ever been convicted of, or charged (but not yet tried) with, a criminal offence?
YesNo

ii. ever been prosecuted (whether or not convicted) under the Health & Safety at Work etc Act 1974, or under any similar statute or regulation?
YesNo

iii. ever been declared bankrupt, gone into insolvent liquidation, been subject to a receivership or an administration order, or been subject to a county court judgement(s)?
YesNo

iv. had any insurer decline insurance, refuse renewal terms, cancel cover, or impose special terms?
YesNo

v. ever suffered any loss, claim or incident which may give rise to a claim at these premises, or any other premises, whether insured hereunder? (if yes, please state further detail)
YesNo

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2. General information

a. Proposer's name

b. Proposer's registered office address

i. Address line 1

ii. Address line 2

iii. Town

iv. Postcode

c. Proposer's business description

d. Proposer's Employer Reference Number

e. What year did the proposer start trading?

f. Are there any subsidiary companies to be added under this policy?

i.

ii.

iii.

g. Does the proposer need to note the interest of a third-party under this policy?

i.

ii.

iii.

h. Policy inception date (inclusive)

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3. Property damage and business interruption underwriting information

a. Main insured location address (if different from registered office address)

i. Address line 1

ii. Address line 2

iii. Town

iv. Postcode

b. Location property damage values

Buildings or tenants’ improvements

Contents (excluding computers and IT equipment)

Computers and IT equipment

Stock

Rent payable

c. Is cover required for any other property at this location? (state items, basis of cover and values below)

i.

ii.

iii.

d. Is 'all-risks' cover required for property away from the main insured location? (state items, basis of cover, territorial limit and values below)

i.

ii.

iii.

e. Is cover required for terrorism related perils?

YesNo

f. Business interruption

i. Basis of cover (e.g. gross revenue/profit, ICOW only, rent receivable)

ii. Sum insured

iii. Indemnity period

g. Location specific underwriting information

Type of tenure

Occupancy

Adjacency risk

Surrounding environment

Building construction and approximate age

Has the location ever suffered from flooding, or is it in a location prone to flooding?

Surrounding environment

Surrounding environment

Surrounding environment

Surrounding environment

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