Proposer's Name
Contact Name
Address
Postcode				Telephone
				Email
Business Description
No of Years In Business				Number of Employees
Renewal Date				Renewal Premium
Premises Information and Cover
Address of Property if different
Construction of the premises.
-Walls - Brick Brick/Steel Steel Wood Concrete Other - Roof - Slate Steel Concrete Timber/Felt Other - Floors - Concrete Stone Wood Other - Heating - Gas CH Electric Oil Portable Heaters None
- Electrics Checked - Less than 12 months Less than 3 years Less than 5 Years Other - Intruder Alarm - BT Redcare Digital Commmunicator Bells Only None - Alarm Maintained - Yes No - Other Occupants - Yes No
Other occupants		No Yes			if yes
Approved Alarm		No NACOSS SSAIB			Alarm Signalling		None Bells Only Digicom Redcare
Property Sums Insured
Buildings						£
Loss of rent						£
Stock (exc Wines and Spirits and Tobacco)						£
Stock of Wines and Spirits						£
Stock of Cigarettes and Tobacco						£
Business Contents (ex Computers)						£
Computer Equipment						£
Tenants Improvements						£
Deterioration of Frozen Stock						£
Business Interruption / Loss of Profits						£ Estimated Gross Profit
Business Interruption Indemnity Period						Months
Book Debts						£
Cash during business hours						£
Cash in Safe						£
Turnover						£
Clerical and Sales Wages						£
All Other Employee Wages						£
Goods in Transit						£		Number of Vehicles
Legal Expenses						No Yes
Contract Cover						No Yes
3 Years Claims Experience
Date			Cause			Amount
Please use this space to tell us about any other factors that you may feel are important or may affect the opinion of underwriters in assessing the risks associated with the insurance proposed.