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


Surname



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)


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

YesNo

Please provide all relevant details




Financial
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


Buildings


Stock


Contents


Goods In Transit


Portable Equipment



Food, Drink & Entertainment
Do you operate a kitchen?

YesNo

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

/ /


Delivery Drivers Do You use Delivery Drivers?

YesNo

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?

YesNo

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?

YesNo

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



Material Facts Are there material fact changes?

YesNo

Please provide details


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

YesNo

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?

YesNo


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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