Name		-Choose- Mr Mrs Miss Dr	Company Name/Trading Name
No and street		Postcode
Telephone		Email
Business Description	Night Club Late Bar Lap and Table Dancing Other see below	if unlisted please specify otherwise leave blank

Please describe the nature of live entertainments.

Do you charge an admission fee for entrance?

Yes No

Date Business Established

DD/MM/YY

	Open	Closed
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

-Walls- Brick Brick/Steel Steel Wood Concrete Other -Roof- Slate Steel Concrete Timber/Felt Other -Floors- Concrete Stone Wood Other ATM/Cash Machine No ATM Cash Machine Yes-inside premises Yes-outside premises -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- NACOSS Approved BT Redcare SSAIB Approved BT Redcare NACOSS Approved Digital Commmunicator SSAIB Approved Digital Communicator Bells Only Alarm None Shop Front Protection   -Choose- Roller Shutters External Grilles Internal Grilles None Accessible Windows Protection   -Choose- Grilles and Window Locks Window Locks Internal Grilles None

Childrens Play Area No Yes -Food Please Choose- No Food Sandwiches and Cold Snacks Bar Meals No Deep Fat Frying Bar Meals inc Deep Fat Frying Full Restaurant Facilities -Accomodation Please Choose- None 1 Guest Bedroom 2 Guest Bedrooms 3 Guest Bedrooms 4 Guest Bedrooms

Buildings	£	Landlords Fixtures/Tenants Improvements	£
Stock excluding items below	£	Wines and Spirits	£
Cigarettes and Tobacco	£	Shop Fronts and Fascia	£ includes neon signs
All other contents	£	Electronic Business Machines
Business Interruption	£	Loss of Money	Cash in Transit £	Cash in Safe£
Loss of License	Choose Yes No	Sum Insured	£
Frozen Foods Cover	Choose Yes No	Sum Insured	£
Goods in Transit	Choose Yes No	Please Select £1,000 £2,500 £5,000

Claims	Date	Cause	Amount