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.


Who is completing this Form:

Job Title:

Business Name:

Trading Name:

Phone number:



Correspondence Address:

Risk Address (if different):

Company Registration Number:N/A

Employee PAYE Reference Number:N/A

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:

What is the Legal Status of this business:
From whom are we permitted to accept instructions in relation to the proposed insurance:ProprietorPartners/DirectorsProfessional AdvisorsStaffBanks/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 & Declinatures

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

Please provide details:

Prosecutions and Convictions

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


Renewal Date:

Previous Claims and Incidents

Are there any incidents or losses that would give rise to a potential claim within the last 5 years: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):







These questions are about the people who own, manage or run the business and not about the business itself.

Has any Principal, Partner or Director or any senior management ever been declared 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 had an insurance proposal declined:YesNo

Has any Principal, Partner or Director or any senior management within the last 5 years been charged with a criminal conviction (excluding motoring convictions):YesNo

Claims History for Individual 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 or 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 £5,000:YesNo

Please provide details:

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





Outstanding Amount


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:


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 provide any details you have for review.

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:


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 occupied:YesNoDon't Know

Are there any unoccupied areas at the Risk Address:YesNoDon't Know

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

Fire Prevention

Has a Fire Risk Assessment been carried out on your premises:YesNoDon't Know

If so, when was it carried out:

Can you confirm if the premises have appropriate fire extinguishers:YesNo

Are these subject to an annual maintenance contract:YesNo

Do the premises have a sprinkler system:YesNoDon't Know

Do the premises have a fire alarm system:YesNoDon't Know

Is the fire alarm system linked to remote alarm signalling:YesNo

Do the premises have a smoke detection system:YesNoDon't Know

is this linked to remote alarm signalling:YesNo

Do you have a closing procedure?:YesNo

As part of your closing procedure do you ensure that there are no smouldering matches, tobacco or hazardous materials within the premises?:YesNo

Upon Discovery of such materials are the potential hazards dealt with:YesNo


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

Please provide details:


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:


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

Age of premises:

No of storeys in total:

Storeys occupied by you:

Is the building listed:YesNo

Is the building:

Please provide more details:

Is there composite panelling:YesNoDon't Know

What is the Composite Panelling infill:PolystyrenePUREPSFoamPolyisocyanate (PIR)RockwoolMineral FibreDon't Know

What % is composite panelling:


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

Please provide details:

Has the property or surrounding area been subject to:SubsidenceHeavingLandslipDon't Know


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:

Do you have a valid NICEIC electrical inspection condition report for your premises:YesNo

When was the certificate issued:

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

When was the certificate issued:


How are the premises heated:Electric fan heaterOil filled radiatorLPG gas heaterPortable paraffin heaterFixed open fire with flue

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






Final Exit Door







Rear Exit Doors







Fire Door














Is there a fire resistant cabinet in the premises:YesNoDon't Know

Passive Security Systems

Is there a burglar alarm installed on your premises:YesNo

Is the alarm installer registered with NICEIC:YesNo

Is your alarm under an annual maintenance contract:YesNo

Who Maintains the alarm system:

Does the alarm system communicate externally:YesNo

Method of signalling:Bells OnlyRedCareOther

Please provide details:


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):


How often is waste removed from the premises:MonthlyFortnightlyWeeklyDaily

How far from the premises is the waste stored:

Is the removed waste kept in metal containers:YesNo

If not kept in metal containers how is waste stored:

Deterioration of Stock

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

Please be aware without a maintenance contract in place the stock will not be insurable


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:


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


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

Is the Frying Range/Cooking Range annually serviced by a professional specialist contractor:YesNo

Is the Frying Range/Cooking Range annually Deep Cleaned by a specialist contractor:YesNo

Who cleans it:

Do you have a valid duct cleaning certificate:YesNo

Date of last certified clean:

Do you Deliver Food:YesNo

Are your Drivers:EmployedAgencySelf Employed

How do you verify delivery drivers are adequately insured:

Alcohol License

Does the premises need an alcohol license to operate: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 in your premises exceed 85 Decibels:NeverOftenOccasionallyUnsure

Is there a dance floor within your premises:YesNo

Are acts of a sexual nature performed as an act of entertainment within your premises:YesNo


Do you ensure that anyone working on your premises have at least a 5 million limit of indemnity 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):


Working at height: (10 Meters)


Working at depth: (3 Meters)


Working with naked flame (away from premises):


Heat work away from your premises:


Power Driven Machinery:


* High Risk Locations:


* 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 you own vehicles:YesNo

Do you use:EmployeePrivateCompany

Are employee vehicles insured for business use:YesNo

What is the maximum value in transit:

What is the maximum value in any one consignment:

How many vehicles are in your care, custody or control:

Do you use couriers:YesNo

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

What is the maximum value in transit:

What is the maximum value in any one consignment:

Importing / Exporting

Do you:ImportExportBoth

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


% Turnover



United Kingdom

European Union

North America / USA

Rest of World

What are your sending methods for Goods:AirLandSea

When Importing do you have legal recourse against manufacturers:YesNoDon't know

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

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

What is the amount you are willing to deduct from each claim:£500£1,000£2,500£5,000+


Sums Insured (£)


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


Portable Devices


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


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






Clerical, Non Manual & Managerial


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:



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


Printed Name: