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	<-Please Select-> Antique dealing Antique furniture retailing Antique/rare books dealing Antiques retailing Aquarium supplier Aromatherapy Art dealing Artist materials retailing Arts and crafts retailing Baby goods retailing Babywear retailing Baker excluding baking Bakers including Baking Bakers supplies Barber Basket and/or brushware retailer Bathroom equipment retailing Beautician Beauty products Beauty salon Bed retailing Bedding retailing Belts/scarves/gloves retailing Booking agency Bookselling Bookselling - second-hand Bottled gas supplying Bridal wear retailing Builders merchants Burger bars Butcher Cafe Camping and outdoor retailing Candle dealing Car accessory dealing Car hiring Carpet (oriental/persian) retailing Carpet retailing Catering equipment supplier Ceramics and pottery Chandlery Charity shop Chemist - dispensing Chemist - non dispensing Childrens clothing retailing China and/or glassware retailing Chiropody Clock and watch repair Clock and watch retailing Clothing hiring Clothing hiring - fancy dress Clothing retailing Coffee and tea retailing Coffee shop Coin & medal dealing Computer games retailing Computer retailing - business Computer retailing - general Computer retailing - home & games Curios retailing Confectionery Cutlery retailing Cycle shop Dairy products retailing Delicatessen Diy store Dog beautician Dolls/dolls house retailing Double glazing Draper Dress agency Dry cleaning Dry cleaning (receiving service) Electrical goods retailing Electrical goods retailing - domestic appliances Electrical goods retailing - hi fi audio tv Electrical goods retailing - white goods Fabric retailing Fancy goods retailing Farm produce retailing Fashion accessories retailing Fashion boutique Fashion retailing Fast food delivery retailing Film processing Fireplace retailing Fishing tackle retailing Fishmonger Florists Footwear retailing Freezer centre Frozen food retailing Fruiterer Furniture retailing Furniture retailing - nursery Garden centre Garden equipment retailing Garden supplies shop General store Gift shop Glass/glass goods decorators or engravers Greengrocer Greeting card retailing Grocer Haberdashery Hairdressing Hairpiece and wig retailing Handicraft retailing Hardware/ironmongery warehousing Health food retailer Herbs and spices retailing Hobby shop Home brew materials retailing Horticultural goods retailing Household goods retailing Ice cream parlour In car entertainment retailing Intruder alarm retailing Ironmonger Key cutters Kitchen accessories retailing Kitchen/bathroom unit showroom Knitting machine shop Knitwear retailing Launderette (attended) Launderette (unattended) Lawnmowers & garden machinery Leather clothing retailing Leather goods retailing (excluding clothes) Leather goods retailing (including clothes) Linen retailing Leisurewear retailing Lingerie retailing Locksmiths Luggage and handbag retailing Maternity wear retailing Menswear retailer Millinery Mobile phone retailing Model shop Motor accessories retailing Motorcycle accessories retailing Musical instrument retailing Newsagents Novelty/carnival goods retailing Nursery goods shop Off licence Office furniture retailing Office supplies retailing Optician Organic foods retailing Outsize clothing retailing Other - please specify Paint and/or wallpaper retailing Patent office Pens retailing Perambulator retailing Perfume retailing Pet accessory/food store Pet parlour Pet shop Pharmacy Photo processing and printing Photographic equipment repairs Photographic equipment retailing Photographic studio Piano retailing Piano retailing and repairs Picture framing Pine and cane furniture retailing Pizza delivery Plant manufacturing Pond supplier Pool & snooker table retailing Post office - sub Pottery Poultry and game retailing Property services Record cd/cassette & video retailing Recruitment agency Restaurant Restaurant - american Restaurant - british Restaurant - chinese Restaurant - european Restaurant - indian Restaurant - licensed Restaurant - mexican Restaurant - other asian Restaurant - others Restaurant - unlicensed Saddlery and tack retailing Sailing equipment supplier Sandwich bar Saw sales and repairs Scientific instrument retailing Sewing machine shop Shirt retailing Shoe repairing Shoe retailing Silversmith Silverware - manufacturing Snack bar Sofa bed retailing Souvenir - retailing Sports goods retailing Sportswear supplier Stamp dealing Stationer Supermarket Surgical equipment retailer Sweet shop Tailor and outfitter Take away food retailer Tea room Television retailing Textile retailing Theatre and ticket agency Ticket agency Tobacconist Toiletries retailing Tool retailer Toys and Games Retailing Trade association Travel Agency Trophy retailing Tv and radio Uniform retailing Vacuum cleaner repairs and service Video equipment and tape retailing Video hire Wallpaper supplier Washing machine repairs and servicing Watch and clock retailing Watchmaker Wine and spirit merchant Wine bar Wool and needlework shop Woollen goods shop	Unlisted trade

-Choose- Shop - Proposer lives on premises Shop- Employee Lives on Premises Shop - Manager Lives on Premises Lock up Shop Lock up shop with dwelling upstairs 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 Roller Shutters External Grilles Internal Grilles None Window Protection Grilles and Window Locks Window Locks Internal Grilles None

-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	£	Full rebuilding cost
	Year Built (Approx)
	Landlords Fixtures and/or Tenants Improvements	£
	Stock excluding items below	£
	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.