Full Client Name

Phone

Email Address

Address

Status of Entity

Trade

Year Business Established

Previous Insurer

Convictions
YesNo
Bankruptcy
YesNo
Policy Voided
YesNo
Insurance Cancelled
YesNo
Renewal Declined
YesNo
Special Terms Applied
YesNo

County Court Judgement
YesNo
Previous Losses

Number of subsidiary companies

The business does comply (where applicable) with the requirements of the Regulatory Reform (Fire Safety) Order 2005 or the equivalent legislation in Scotland and Northern Ireland:
YesNo
Is the insured exempt from holding a HM Revenue & Customs Employer`s PAYE Reference Number?
YesNo

Effective Date

Listed Building
YesNo

Premises Address

Property Type

Number of Flats

Year Built

Date of Purchase

The property is of non-standard construction [walls not built only of brick, stone or concrete or roofed only with slates, tiles or concrete]
YesNo
The property has external cladding/external wall insulatio
YesNo
Building roof is flat or partially flat
YesNo
You are aware of any previous flooding at the premises, whether or not it was insured and whether or not a claim was made
YesNo
The property or adjacent property has suffered from, or shows any visible signs of damage from subsidence, landslip or ground heave
YesNo
ATM on Premises
YesNo

Building Wall Material

Wall Construction Percentage

Building Roof Material

Roof Construction Percentage

Flat Roof Percentage

Number of storeys where floor is of concrete construction

Number of storeys where floor is of wooden construction

Heating Type

Rebuild Value (£)

Monthly Rental Income (£)

Indemnity Period (months)

Occupant Type

Premises is a House in Multiple Occupation (HMO)
YesNo

Any part of the premises is unoccupied
YesNo