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

Legal Status of Proposer
What type of Business Structure do you have?:

Insurance Policy Start Date

Inception Date: / /

Company Registration Number (if applicable):
Employee PAYE Reference Number (if applicable):

Permission to Share Information
From whom are we permitted to accept instructions/ share information in relation to the proposed insurance, please select to whom we should accept instructions:YesNo

Business Activities
Please provide a full description of Business Activities:

Trading History
How long Approximately has the business traded:
At Risk Address?: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
Has the proposer 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

Business proposer history
Has any Principal, Partner or Director ever been made bankrupt, or been in a business that has been sequestrated, liquidated or placed into administration?:
Has any Principal, Partner or Director 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

Insurance Current / History
Do you have a current insurance Policy:YesNo
Who With:

Claims History for Principal, Partner & Director
Please note the following question is not confined to the history of the business proposed in isolation, but includes the insurance history of the individuals owning, controlling or running the business either in their personal capacity or in other business interests.
Has the proposer’s sustained any loss or damage during the last five years at this or any other premises, which would have been covered by this type of insurance had it been in force?

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

Criminal 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 information is disclosed however the Underwriters will be entitled to act upon it. If you are in doubt about wether a conviction is ‘spent’ please consult with your legal advisors.
Has any Principal, Partner or Director ever been convicted of or charged (but not yet tried) with arson or any offence involving dishonesty of any kind ( eg fraud, robbery, theft or handling stolen goods)?

Risk address and Covers Required
What is the risk address?
What is the property used for?
Are you the sole Occupier?YesNo
Who else is there?
Are Adjoining Properties Occupied?YesNo
Are there any unoccupied or vacant areas at the risk address?YesNo
Further Information:

Construction of the Premises
Roof type?
Is any of the roof flat?
Walls Material?
Floor Material?
State of repair?
Age of premises?
Stories occupied by you?
No of stories in total?
Is the building listed?
Is there Composite Panelling?

Are there any subsidence Issues at the property that you are aware of or have been reported?YesNo
Further Details:

If there is a basement?YesNo
Is the Basement Used?YesNo
Please provide info about stock and usage of basement?

Electrical Installation
When was the electrical system installed and when was it last inspected? / /
If you are responsible for the electrical installation can you confirm the premises have a current IEE certificate?YesNo
Please describe your Portable Appliance Testing procedure
Is there a current Fire Risk Assessment in place?YesNo

How are the premises heated?
Are there any portable heaters on the premises?YesNo

Are there any manufacturing processes carried out on the premises?YesNo
Are There any flammable oils or other hazardous goods stored or used on the premises?YesNo
Does your business involves the use of Frying and Cooking Equipment:YesNo
The Frying Range is annually serviced by a professional specialist contractor including the servicing of the extraction fan and motor?YesNo
The extraction ducting and fan is deep cleaned annually by which specialist contractor?
A fire blanket and suitable fire extinguisher are kept in the kitchen area and are subject to an annual maintenance contract?YesNo

How often is waste removed from the premises?
How far from the premises is the waste stored?
Is the waste removed from the premises kept in metal containers?YesNo
Please Describe

Fire Prevention
The various Fire Regulations give everyone involved in a building a statutory responsibility to work together to make sure a Fire Risk Assessment is carried out. This is a legal requirement and should be reviewed annually or as other wise required.
Can you confirm the premises has appropriate Fire Extinguishers and these are subject to an annual maintenance contract?YesNo
Does the Premises have a sprinkler system?YesNo
Does the premises have a Fire Alarm system?YesNo
If Yes, Is this linked to remote alarm signalling?YesNo
Does the premises have a smoke detection system and is this linked to remote alarm signalling?YesNo
Is a thorough inspection conducted at the close of the business to allow for smoldering matches, tobacco or other material?YesNo

Is the building in a recognised Flood Area?YesNo
Have there been any cases of Flood at the premises or in the vicinity?YesNo
Are there any rivers, streams or tidal waters in the neighbourhood?

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:
Final Exit Door?
Rear Exit Doors?
Fire Door?
Accessible Windows?
Is there a security safe in the premises?YesNo
Is there a fire resistant cabinet in the premises?YesNo

Passive Security Systems
Alarm System
Is there a burglar alarm installed on your premises?YesNo
CCTV System
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 etc):

Frozen Food
Are all refrigerated units subject to an annual insurance maintenance contract? (Please note that this is a condition of your policy)YesNo

Is Money moved between your Premises and the Bank?:YesNo

Loss of License
Do you require loss of license cover?YesNo

Employer’s, Public, Products & property Owner’s Liability
An Employee is described as a person under a contract or service or apprenticeship with the Assured. It also extends to include self employed persons under the control of the Assured, Persons hired to or borrowed by the Assured or persons undertaking study or work experience with the Assured.
Public & Products Liability Standard Limit of Indemnity
Standard Limit of Indemnity is £1,000,000, Please tick if you require additional covers:No Extra2 Million5 Million10 Million

Estimated annual wages, salaries and all other payments for the next twelve months
Clerical, non manual and managerial Count: Wageroll:
Manual Workers Count: Wageroll:
Bona Fide Sub Contractors Count: Wageroll:
Labour Only Subcontractors Count: Wageroll:
Stewards Count: Wageroll:
What is the annual Turnover of the business and has the increased or decreased in the last 12 months:

Contractors & Turnover
Do your ensure that all subcontractors engaged have adequate Liability insurance in force and do the limits match those of the proposed insurance?
Do your activities expose your employees to any of the following:
Excessive noise (higher than 80db):YesNo
Working at height:YesNo
Working at depth:YesNo
Working with naked flame: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

Business Practices
Does your business:
Export, Directly or indirectly, to the USA or North America?YesNo
Design or prepare specifications for a fee or 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
Does your business involved the use of toxic and/or hazardous goods, materials, substances and/or waste?YesNo
Does your business result in any impairment of the environment e.g. chemical effluents, fumes etc?YesNo

Sum’s Insured
Tenants Improvements:
Loss of Rent (Up to 12 Months):
Target Stock:
Of which Alcohol:
Of which Tobacco:
Of which Any Other Target Stock:
General Stock:
External and Neon / Illuminated Signs:
Machinery, Plant & Equipment:

*Debris Removed – All Stock (Included)


Extension 1 -Accidental Damage
Accidental DamageYesNo

Extension 2 -Breakage of Glass
Breakage of GlassYesNo Sums Insured:

Extension 3 -Specified Property
Specified PropertyYesNo Sums Insured:

Extension 4 -Food Spoilage
Standard Policy Limit is £1,000.00 All Refrigerating Units (any one unit)YesNo Sums Insured:

Money Non Negotiable Documents and Assault
Standard Limits are noted, if these require amending, please advise with your changes
Sum’s Insured(Standard Limits)
Non Negotiable Documents: (*£100,000)
In the Premises outside Business Hours: (Not contained in locked safes or strongrooms) (*£250)
Private residence: (*Not insured)
In the Premises outside Business Hours (Contained in locked safes or strongrooms): (*£3,000)
On the Premises During Business Hours: (*£5,000)
In Transit: (*£5,000)
In a gaming, amusement or vending machine: (*£200 / machine; £400 total)
Loss or damage done by thieves to safes and strongrooms: (*Not Insured)

*Standard Limits

Goods In Transit
Standard policy limit is £1,000.00
In Transit (any one conveyance):

Book Debts
Outstanding Debit Balances:
Auditors or Professional Accountant Charges:

Loss of License
loss of License:

Business Interruption
Standard Limit is £500,000 over 24 months
On Gross Profit (Maximum Indemnity period: 24 Months):
On Gross Profit – Declaration Linked (Maximum Indemnity period: 24 Months):
On Increased Cost of Working (Maximum Indemnity Period: 12 Months):
Auditors or Professional Accountant Charges:

Material Facts & Declaration
Material Facts
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?YesNo




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.


By Clicking “Send” you confirm the above information is a fair presentation of the risks associated with the business for our forthcoming insurance renewal.


I have conferred with senior colleagues in compiling the information or have myself of seniority within the business to be able to compile the information.


Your Full Name Position In the Business

Today’s Date:

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