Policy Holder Name: 

Business Name:

Risk Address: 




Employer Reference Number: 

Employer Name as registered with HMRC: 

Have there been any changes in ownership including Address, Business Activities, Occupation of Premises: 

Details of any alterations to construction, security or fire protections at the premises: 

Since the policy was last reviewed, please advise any changes to the sums insured under the following sections of cover:




Please advise current figures for:


Wage roll:

Employee Count:

Gross Profit:

Do you Employ Delivery Drivers: YesNo

Are they?: EmployedSelf EmployedAgency

Do you employ Door Stewards: YesNo

Are they?: EmployedSelf EmployedAgency

If applicable, please provide the date(s) on which you’re cooking/frying range and ducting was last "deep cleaned" & serviced:

Can you confirm all Electrical systems in the premises are certified including PAT Testing:YesNo

Details of any other material circumstances (e.g. criminal convictions, HSE prohibitions) we ought to know:

Details of any unreported incidents which could lead to a potential insurance claim:

Has any principal, Partner, Director or any senior management ever been sequestrated or bankrupt, or been in a business that has entered insolvency proceedings, liquidated or placed into administration: YesNo

Details of any additional cover you would like us to provide a quotation or information on: Business InterruptionBusiness TravelCommercial CombinedCommercial PropertyCybercrime & Commercial CrimeDirectors and OfficersEngineering InsuranceIncome ProtectionMarine CargoMotor FleetProduct Liability InsuranceProfessional indemnityPublic LiabilityTerrorism

The additional covers incorporated into my insurances, including Commercial Legal Expenses and Loss Assist, have to be renewed alongside my other business insurance renewals.YesNo

I confirm by submission of this information I have consulted senior management and colleagues to present a Fair Presentation of Risk for this business:Confirmed

Signed By: 

Your Position: 

Date Completed: