About this form You have a statutory duty to make a fair presentation of risk to your insurers. The need for accuracy and honesty in presentation of facts cannot be overstated, To learn more about this duty see Presenting the Facts If you do not have all the information immediately to hand, please complete as much of the information as possible.

First name


Business Name

Risk Address

Phone Number

Email Address

Have there been any changes to Ownership which differs from the information we have on file for you? YesNo

Tell us about details of any changes in ownership (Including Director's)

Business Details

Employer Reference Number

Employer Name as registered with HMRC (including all subsidiary companies)

Have there been any changes or alterations to construction, security or fire protections to the Property?


Please provide all relevant details

What changes have there been to the financial information over the last 12 Months?

Turnover for this Financial Year

Gross Profit for this Financial Year

Clerical Wageroll Figure for Year

Clerical Employee Count

Manual Wageroll Figure for Year

Manual Employee Count

Sum's Insured Changes




Goods In Transit

Portable Equipment

Food, Drink & Entertainment
Do you operate a kitchen?


Kitchen Duct/ Extraction Cleaning If applicable please provide dates on when your frying range and ducting was last deep cleaned and serviced:

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Delivery Drivers Do You use Delivery Drivers?


Are they your employees or self employed?

EmployeeSelf Employed

How many Delivery Drivers?

How many hours do they work?

Wageroll Per Year (£)?

Doormen Do You use Doormen for premises Security?


Are they your employees or agency workers? EmployeeAgency

How many Doormen?

How many hours do they work?

Wageroll Per Year (£)?

Potential Insurance Claims/Incidents Please consult your Accident Book before completing question.

Are there any known potential claims?


Are you aware of any unreported incidents or loss that could give rise to a potential claim.

Material Facts Are there material fact changes?


Please provide details

Have there been any other material facts (e.g. Criminal Convictions, HSE Prohibitions) we require?


Please provide details

Additional Information

Anything else we should know?

Legal Expenses & Loss Assist

Routinely we include commercial Legal Expenses insurance and Loss Assist cover as part of our package. Please confirm below if you wish to include these covers. Do you wish to have these additional coverages?


Details of any other policies you would like information on

Business InterruptionBusiness TravelCommercial PropertyCyber and Commercial CrimeDirectors and OfficersEmployers LiabilityEngineeringMarine CargoMotor FleetProduct LiabilityBusiness ProtectionProfessional IndemnityPublic LiabilityTerrorism

Declaration By Clicking "Send" you agree to be contacted by an FCA Authorised Advisor and confirm that you have read & agree with our Terms & Conditions and Privacy Policy. The Business Insurance Bureau is authorised and regulated by the Financial Conduct Authority (FCA) and our registration number is 307026. We are authorised to conduct General Insurance and this can be verified by contacting the Financial Conduct Authority (FCA) on 0845-606-1234 or www.fca.gov.uk/register.

Alterations and changes to policy's are not instantly active, nor should be considered acted upon until the business has had the opportunity to contact the insurers regarding your policy to make them aware of the facts.

Confirm Name

Position In Business

Today's Date:
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