Surname		Forenames		Title	-Choose- Mr Mrs Miss Dr
Company/Trading Name
Adresss				Province
Telephone		Mobile		Email Address

Business Description

Who else occupies the premises?

-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

Date Business Established

The Premises
-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
-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

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

Claims Have you had any losses in the last three years?

Please Choose Yes No

Please include type of claim, dates and amounts paid

Please use this space to provide any other information that you feel may be important or relevant.