Surgery Insurance Quotation Form
|
|
Proposer's and Business
Description Details |
|
Proposer's name: |
|
|
Company trading name: |
|
|
Date business established : |
|
|
Is the business: |
|
|
Business description or trade:
(please describe all your activities to be insured): |
|
|
Address of property to be insured: |
|
|
Postcode: |
|
|
About The Building |
|
What cover do you require?: |
|
|
If Buildings Cover Is Required, What Sum Insured?: |
|
|
Is the building... (please complete even if
only insuring contents) |
|
Constructed of brick, stone or concrete and roofed with
slates, tiles, concrete, metal or asbestos sheeting? : |
Yes
No |
|
Maintained in a good state of repair?: |
Yes
No
|
|
Occupied by you in connection with your business and as a
private dwelling?: |
Yes
No |
|
Heated only by a low pressure hot water apparatus, fixed gas
appliances or fixed electrical appliances?: |
Yes
No |
|
If you have answered 'no'
to any of
the above, please give details here |
|
|
About The Contents |
|
Please give the sum insured
required for each category: |
|
Category |
Sum insured (£)
|
|
Business equipment (including
fixtures and fittings and all other contents for which you are legally
responsible for but excluding computers): |
|
|
Business files and records: |
|
|
Computers and electrical
equipment: |
|
|
Fixed glass: |
|
|
Contents to be covered away
from the premises (Please describe the equipment to be covered in
'material facts box at bottom of form'): |
|
|
Optional Covers |
|
|
Business interruption:
(Estimated GROSS REVENUE for next 12 months) |
|
|
Is terrorism cover required?: |
Yes
No
|
|
More About The
Insured And Premises |
|
Has the Insured or any director
or partner been declared bankrupt, insolvent, been convicted of or has any
prosecution pending for arson or any offence involving dishonesty of any
kind?: |
Yes
No
|
|
Has any previous insurer
declined a proposal, refused to renew a policy or imposed any special
terms or conditions?: |
Yes
No
|
|
Has the Insured or any director or partner
incurred any loss, destruction or damage or had any claim made against
them in the last 5 years? |
Yes
No
|
|
Does the Insured undertake to work away from
the premises? |
Yes
No |
|
Does any other business occupy or operate from
these buildings? |
Yes
No |
|
Are the premises in an area
which is exposed to damage by storm, flood, subsidence, heave or landslip,
or near a river, sea, watercourse, cliff or quarry?: |
Yes
No
|
|
Is there a safe at the
premises?: |
Yes
No |
|
If the answer is 'yes' to any of
the above, please provide full details in the box here:
|
|