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 SelectConstructionFood, Drink & EntertainmentProperty OwnerManufacturingProfessionRetailServiceLandlordOther Please provide some details: What type of insurance do you would you require:Please SelectCombined PackagePublic LiabilityEmployers LiabilityProduct LiabilityCybercrimeContract WorksLegal ExpensesPropertyUnsure Let us know what your business does to help you find the right insurance coverages: What is the Legal Status of this business:Please SelectLimited CompanySole TraderPartnershipUnincorporated Association (i.e. Club or voluntary Group)LLP (Scotland)LLP Company 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:TileSlateFlatThatchOther 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:ElectricGasDiesel 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 If so, do you give advice in connection with products supplied: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:
