Please complete as much of the form as possible, If you cannot complete the entire form do not worry, complete what you can and click "Submit" below, Should we require anything else we will call you for information.

Please consult with senior colleagues and management in the completion of this form.

Basics

Who is completing this Form:

Job Title:

Business Name:

Trading Name:

Phone number:

Email:

Mobile:

Correspondence Address:

Risk Address (if different):

Company Registration Number (if applicable):

Employee PAYE Reference Number (if applicable):

From which date would you like the cover to start from:


In which sector/industry is your business based:

Please provide some details:

What type of insurance do you would you require:

Let us know what your business does to help you find the right insurance coverages:

What is the Legal Status of this business:
From whom are we permitted to accept instructions in relation to the proposed insurance:Partners/DirectorsProfessionalAdvisorsStaffBanks/Lenders


Trading History

How long approximately has the business traded:
Years at this Risk Address:
Years at another address:
Is the business multi location:YesNo


Cancellations, Refusals & Declined Past Policies

Has any insurer declined to accept, cancelled or refused to continue any insurance of this nature with the proposer:YesNo

Please provide details:

Has the Business ever been prosecuted under the Factories Act 1961, Health & Safety at Work Act 1974, the Consumer Protection Act 1987 or any other statutory regulations:YesNo

Please provide details:


Current Insurance

Do you have a current insurance policy:YesNo

Insurer:

Renewal Date:


Potential Claims

Have you had any insurance claims or incidents that would give rise to a potential claim:YesNo

If you have had any insurance claims or incidents that would give rise to a potential claim, please list them below (Excluding Motor Claims):

Date

Type

Circumstances

Settlement

Outstanding


People

These questions are about the people who own, manage or run the business.

Has any Principal, Partner or Director or any senior management ever been made bankrupt, or been in a business that has been sequestrated, liquidated or placed into administration:YesNo

Please provide details:

Has any Principal, Partner or Director or any senior management within the last 5 years made an insurance claim, had an insurance proposal declined or been charged with a criminal conviction:YesNo


Claims History for Principal, Partner, Director or senior management

Please note the following question is about the insurance history of the individuals owning, controlling or running the business either in their personal capacity for other business interests (i.e. other directorships, past or present).


Has any Principal, Partner or Director or any senior management sustained any insurable/ physical loss or damage during the last five years in a personal or business capacity in excess of £25,000:YesNo

Please provide details:

Have the people of the business made any insurance claims within the last five years:YesNo

Please provide details of Claims Experience of people from within the business over the last five years:

Date

Insurer

Circumstance

Settlement

Outstanding Amount


Declinatures

Has any insurer refused to continue, cancel or decline insurance cover for any Principal, Partner or Directors or senior management of the Business:YesNo

Please provide details:


Convictions

Some convictions are regarded as ‘spent’ under the terms of the Rehabilitation of Offenders Act 1974 and need not to be disclosed in applying for insurance. If you are in doubt about whether a conviction is ‘spent’ please consult with your legal advisors.

Has any Principal, Partner or Director or Senior Management ever been convicted of or charged (but not yet tried) with arson or any offence involving dishonesty of any kind (e.g. fraud, robbery, theft or handling stolen goods):YesNo

Please provide details:







Premises

Do you wish to insure property:YesNo

What is the property used for:

Are you the Sole Occupier of this Risk Address:YesNo

Please provide details of other occupants:

Are adjoining properties surrounding the premises occupied:YesNoUnknown

In the premises are there occupants above or below you:YesNoUnknown

Are there any unoccupied areas at the Risk Address:YesNoUnknown

If there are operational businesses surrounding/ above or below your premises please list the trades these businesses operate in:


Fire Prevention

Are you aware if a Fire Risk Assessment has been carried out on your premises:YesNoUnknown

If so, when was it carried out:

Can you confirm the premises have appropriate fire extinguishers:YesNo

Are these are subject to an annual maintenance contract:YesNo

Do you have a kitchen Fire Risk Assessment in place:YesNo

Do the premises have a sprinkler system:YesNo

Do the premises have a fire alarm system:YesNo

Is this linked to remote alarm signalling:YesNo

Do the premises have a smoke detection system and is this linked to remote alarm signalling:YesNo

Is a thorough inspection conducted at close of business to allow for smoldering matches, tobacco or other material as part of a closing procedure:YesNo


Flood

Is the building in a recognised Flood Area:YesNoDon't know

Have there been any cases of Flood at the premises or in the vicinity:YesNoDon't know

Please provide details:


Construction

Construction of the premises roof type:

Please provide details:

Is any part of the roof flat:YesNo

What % of the roof is flat:

What are the walls made of:

What is the floor made of:


Maintenance

State of repair:Excellent (Constant maintenance programs)Adequate (As and when required)Don’t know

Age of premises:

No of stories in total:

Stories occupied by you:

Is the building listed:YesNo

Please provide details:

Is there composite panelling:YesNo

What % is composite panelling:


Subsidence

Are there any subsidence issues at the property or in the area that you are aware of or have been reported:YesNoDon't know

Please provide details:


Basement

Is there is a basement:YesNo

Is the basement used:YesNo

Is stock kept in the basement:YesNo

If so, is stock kept at least 10cm off the floor:YesNo

Do security measures extend to the basement:YesNo

Please provide details about stock and usage of basement:


Electrical Installation

When was the electrical system installed:

When was it last inspected:

Do you have a valid PAT test certificate for your premises:YesNo

When was the certificate issued:

*Please provide certificates when submitting your Risk Presentation


Heating

How are the premises heated:

Are there any gas or paraffin portable heaters on the premises:YesNo

Please provide details:


Physical Security

Please complete the following questions, soley in relation to security directly and completely under your control. Please advise how each of the following are protected:

Alarm Contact

Locks

Grills

Bars

Bolts

Shutters

Final Exit Door

Yes

Yes

Yes

Yes

Yes

Yes

Rear Exit Doors

Yes

Yes

Yes

Yes

Yes

Yes

Fire Door

Yes

Yes

Yes

Yes

Yes

Yes

Windows

Yes

Yes

Yes

Yes

Yes

Yes

Is there a fire resistant cabinet in the premises:YesNo


Passive Security Systems

Is there a burglar alarm installed on your premises:YesNo

Is the alarm installer registered with NICEIC:YesNo

Does the alarm system communicate externally:YesNo

Method of signalling:Bells OnlyRedCareOther

Please provide details:


CCTV

Is there a CCTV system fitted to the premises:YesNo

Is there an external local authority CCTV system monitoring the vicinity:YesNo

Please advise of any other security measures not under your direct control (e.g. security patrols, guard dogs etc):


Waste

Is waste removed from the premises:YesNo

How often is waste removed from the premises:MonthlyFortnightlyWeeklyDaily

How far from the premises is the waste stored:

Is the waste removed kept in metal containers:YesNo

If not kept in metal containers how is waste stored:


Frozen Food

Are all refrigerated units subject to an annual insurance maintenance contract:YesNo


Money

Is cash kept on the premises:YesNo

How much cash is kept at the premises:

Is Money moved between your premises and the Bank:YesNo

How much is usually moved:

How often:

By how many people:

Do you take cash home:YesNo

*Please be aware only monies directly moved between your premises and the bank will be covered by your insurances.


Safe details

Do you have a safe:YesNo

Make/ Model:

Insurance Rating (if known):

How much money is kept in the safe (at peak trading overnight):


Forklifts

Do you use forklifts:YesNo

How many forklifts are in operation:

Are your forklifts used on public highways:YesNo

Are forklifts:

If you have charging stations for forklifts are they charged overnight:YesNo

Are the charging stations at least 5m from any combustible materials:YesNo






Process

Business Activities

Please provide a full description of business activities:

Are there any manufacturing processes carried out on the premises:YesNo

What manufacturing processes are carried out:

Are there any flammable oils or other hazardous goods stored or used on the premises:YesNo

Please provide details:

Does your business involve the use of Frying and Cooking Equipment:YesNo

Do you Deliver Food:YesNo

Are your Drivers:EmployedAgencySelf Employed

How do you verify delivery drivers are adequately insured:

Is the Frying Range/Cooking Range annually serviced by a professional specialist contractor including the servicing of the extraction fan and motor:YesNo

Who cleans it:

Do you have a valid duct cleaning certificate:YesNo

Date of last certified clean:

*Please provide certificates when submitting your Risk Presentation


Alcohol License

Is an alcohol license involved in your business operations:YesNo

Do you hold an alcohol license:YesNo

To your knowledge, have there been any objections to the license during the last five years:YesNo

Please provide details:

Have the present owner(s) or manager(s) been refused a license at any time:YesNo

Please provide details:

Are there any circumstances known to the proposer that might prejudice the continued holding of a license:YesNo

Please provide details:

Do you employ Door Stewards:NeverOccasionallyConstantly

Are they:EmployeesAgencySelf Employed

Does the Noise on your premises exceed 85 Decibels:NeverOftenOccasionallyUnsure

Is there a Dance Floor within your premises:YesNo

Are acts of a sexual nature performed within your premises:YesNo


Contractors & Turnover

Do you ensure that all subcontractors engaged have at least the same level of Liability insurance in force as you and do the limits match those of the proposed insurance:YesNo

How often do you check this is the case:AnnuallyAt Project Start


Business Process & Employee Exposure

Do your activities expose your employees to any of the following: excessive noise, working at height or depth, power driven machinery or heat work:YesNo

Does your process involve

Yes / No

% of Turnover

Turnover Excessive noise (higher than 80db):

YesNo

Working at height:

YesNo

Working at depth:

YesNo

Working with naked flame (away from premises):

YesNo

Heat work away from your premises:

YesNo

Power Driven Machinery:

YesNo

* High Risk Locations:

YesNo

* High Risk Locations Include Airports, Offshore Installations, Dams, Quarries, Railways, Nuclear Power Stations


Goods Transported within the United Kingdom

Do you collect or deliver stock:YesNo

If so, do you use your own vehicles:YesNo

What is the maximum value in transit in any one vehicle:

What is the maximum value in transit in any one consignment:

How many vehicles do you own:

Do you use couriers:YesNo

If so, how frequently are couriers used:DailyWeeklyBi-WeeklyMonthlyQuarterlyYearly

What is the maximum value in transit in any one vehicle:

What is the maximum value in transit in any one consignment:


Importing / Exporting

Does your Business:Not Import nor ExportImport & Export

If so, do you:ImportExportBoth

Please provide information on the turnover generated by the business in the following geographic locations:

Area

% Turnover

European Union

North America

United States

Rest of World


What are your sending methods for Goods:

When Importing do you have legal recourse against manufacturers:YesNo

Do you have any representation outside the United Kingdom:YesNo

Have you supplied any goods or services for the nuclear, aerospace, marine or offshore industries:YesNo

Please provide details:

Does your business involve the use of toxic and/or hazardous goods, materials, substances and/or waste:YesNo

Please provide details:


Pollution

Does your business result in any impairment of the environment e.g. chemical effluents, fumes etc:YesNo

Please provide details:

Have you ever been fined/ cautioned/ prosecuted by any environmental agency:YesNo

Please provide details:


Computers & Data

Does your business have computers & store data:YesNo

Do you have security controls in place (Antivirus/Malware Protection, Firewalls, Network Access Controls): YesNo

Do you have backup and recovery procedures in place for all mission critical systems, data and information assets:YesNo

Do you have processes in place for managing and installing patches on all systems and assets:YesNo

Do you have processes in place to ensure that all confidential data is encrypted on all portable devices:YesNo

Do you store more than 100,000 records containing personally identifiable information:YesNo

Do you have any knowledge of any security failure, operational failure or data breach that would otherwise have been the subject of a claim or loss under a Cyber policy:YesNo


Assets & Liabilities


Item

Sums Insured (£)

Buildings

Tennants Improvements

Loss of rent cover

12 months24 months36 month

Stock of Alcohol

Stock of Tobacco

Stock in the Open

Stock of Alcohol

High Value attractive Stock

All other Stock

Chilled & Frozen Foods

External and Illuminated Signs

Fixtures & Fittings

Machinery, Plant & Equipment

Electrical Equipment

Computers

Portable Devices

Other


Sums Insured

Money in the premises outside business hours (not contained in locked safes or strongrooms):

Private residence:

In the premises outside business hours (contained in locked safes or strongrooms):

On the premises during business hours:

In transit:

In gaming, amusement or vending machines:


Business Interruption

Annual gross profit:

Indemnity period:6 Months12 Months24 Months36 Months

Annual increased cost of working:

Indemnity period:6 Months12 Months24 Months


Liabilities

Annual Turnover and/or fee income of the business in the last 12 months:

Employers Liability Cover:£10 Million

Public Liability Cover:£5 Million£10 Million

Products Liability Cover:£5 Million£10 Million

Management Liability Cover:£100k£250k£500k£1million

Cyber Liability Cover:£250k£500k£1million£5million

Professional Indemnity Cover:£250k£500k£1million£5million



Wageroll & Turnover

Please provide estimated annual wages, salaries and all other payments for the next twelve months full time and part time:

Working on Premises

Working Away

Activity

Number

Wageroll

Number

Wageroll

Clerical, Non Manual & Managerial

Stewards

Delivery Drivers

Woodworking Machinists

Working at Height

Working at Depth

Working with Hazardous Substances (e.g. Asbestos)

Naked Flame & Heat Work

Power Driven Machinery

Other Manual labour

Payments to Bona Fide Sub Contractors

Payments to Labour Only Sub Contractors

If you use Labour Only Subcontractors - what do they do:

Other Manual Workers - what do they do:



Material Facts & Declaration

Are there any other material facts (see proposal introduction and declaration below) not already disclosed affecting or likely to influence acceptance or assessment of this proposal by underwriters:

Please provide details:

I have read and checked this proposal for completeness and accuracy. To the best of my knowledge and belief, I confirm that the information given, whether in my own hand or not is complete and accurate.

I understand that this proposal does not bind the Proposer to complete the insurance but, if accepted, this proposal will form the basis of the contract between the Proposer and the Underwriters.

I understand that any material misrepresentation or non-disclosure may lead to avoidance of the insurance by the Underwriters. I understand that any information provided to the Underwriters regarding the Proposer will be processed by the Underwriters, in compliance with the provisions of the Data Protection Act 1988, for the purpose of providing insurance and handling claims which may necessitate providing such information to third parties.

Have colleagues contributed to the completion of this Risk Presentation Proposal:Yes

Please provide details of colleagues who contributed to this Risk Presentation:

Name

Position

I confirm that I am duly authorised by the Proposer to make this declaration.

Signature:

Printed Name:

Position:

Date: