Specialist Insurance: Online Quote

SECTION A - General

1. Name & Full Trading Title:

2. Address:

3. Full Business Description:

4. Website Address:

5. How long have you been in business:

6. Previous Insurers:Renewal Date:

7. Please provide full details of the building construction (ie Brick/Stone/Composite panelling incl infill/Asbestos etc.)

8. Please provide full details of the roof construction:

9. Are internal floors constructed of timber or any material other than concrete?

10. Is the buiding protected by an intruder alarm /fire alarm?YesNo

    Is it connected to a centrally monitored station?YesNo

    Does the alarm conform with the ISEN50131 standard?YesNo

    Other security precautions:

    Nearest Fire Brigade: km Full/Part time

    Does the building have a sprinkler system that covers 100% of the floor area?YesNo

    If YES, is the sprinkler system under a maintenance contract?

11. Is the building solely occupied by you in respect of the business description described above?YesNo

    If NO, please supply details of other tenants:
    

12. Is the area prone to subsidence/flooding?YesNo

    If YES, please provide further details:
    

13. Are any of the premises partly unoccupied?YesNo

    If YES, please provide further details:
    

14. Is the heating, one of the following?YesNo

    Low pressure hot water apparatus, fixed oil-fired space heaters (not tropical type), wall mounted electric or gas radiant or convector heaters.

    Please provide details:
    

SECTION B - Property

SECTION C - Liability

Standard PL 6.5M and EL 13M Please advise if higher limit required

Please provide details of goods manufactured, sold or supplied:

Does the proposer work at heights (over 10 metres) or depths (over 1 metre)?YesNo

If YES, please provide details:

Do you work away from premises and if so, please provide further details:

Does the proposer handle hazardous substances?YesNo

If YES, please provide details:

Does the Prosper carry out any heat work away?YesNo

If YES please provide details:

SECTION D

SECTION E

SECTION F - ALL RISKS

Are All Risks specified Items Required

SECTION G - MONEY

Only complete if money is required

Estimated Annual Cash Carryings

Negotiable Money

1. On premises during business hours or in transit or in bank safe

2. In locked safe

   Safe Type:Serial No.

3. On premises out of business hours not locked in a safe

Not Negotiable Money €250,000

SECTION H - GOODS IN TRANSIT

Only complete if Goods is transit is required

Estimated Carryings/Sendings

Max. Value any one vehicle

SECTION I - LOSS OF LICENCE

Loss of Licence

SECTION J - CLAIMS

PREVIOUS CLAIMS HISTORY (5 YEARS)

Property/Business Interruption

Employers Liability

Public/Products Liability

Are you aware of any Director or Senior figure of the propsed who has had an insurance declined or cancelled, insurance renewed ony on special terms or been declared bankrupt or entered into any arrangement with creditors? If so please provide further details:

DECLARATION

I/We declare that to the best of my/our knowledge and belief, the above statements made by me/us or on my/our behalf are true and complete and that I/We have not surpressed, misrepresented or misstated any material fact.

Signed:

Broker:Date