Name		-Choose- Mr Mrs Miss Dr
Company/Trading Name
No and street		address of the premises to be insured
		Postcode
Telephone		Email Address
Date of Expiry of existing insurance/ or required from		Year Business Established
Business Description		Unlisted trade

-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 Roller Shutters External Grilles Internal Grilles None Window Protection Grilles and Window Locks Window Locks Internal Grilles None No Car Wash Drive Through Pressure Washers

-Walls- Brick Brick/Steel Stone Steel Wood Concrete Other -Roof- Slate Steel Concrete Timber/Felt Other Timber Felt Flat Roof% None Less than 10% Less than 25% Less than 50% More than 50%   -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

If there is deep fat frying on the premises please confirm	-Choose- Free Standing Table Top Basket None -Choose- Less than 1 Year Less than 2 years Less Than 3 Years Less than 4 Years Less than 5 Years Over 5 Years Over 20 Years No Range	Value of Range
Sums Insured

	Buildings including canopies	£	Full rebuilding cost
	Year Built (Approx)
	Landlords Fixtures and/or Tenants Improvements	£
	Pumps	£
	Stock excluding items below	£
	Fuel in Tanks	£
	Wines and Spirits	£
	Cigarettes and Tobacco	£
	Video Tapes, CD, DVDs for Sale or Hire	£
	Shop Fronts and Fascia	£	includes neon signs
	All other contents	£	Fixtures and fittings and equipment
	Electronic Business Machines	£	Tills, cash registers, computers etc
	Business Interruption	£	Estimated Gross Profit for 12 months

	Loss of Money	Cash in Transit	£	Cash in Safe	£
	Loss of License	No Yes	£
	Frozen Foods Cover	No Yes	£
	Goods in Transit	No Yes	Please Select £1,000 £2,500 £5,000

Claims Last 5 Years	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.