Small Business

Please complete all of the following fields.
**Denotes compulsory field

Name Of Business

Contact Name **

Contact Number **

Email Address **

Preferred contact method

Please select Phone Email

Are you a new or existing client?

Please select New Existing

If new, please advise how you got our name

Please select Websearch Recommendation Advertising Other

If existing, please enter your Client Reference if known

Do you currently have Office insurance for this business?

Please select Yes No

If yes, what is the renewal date?

D: M: Y:

What is the current annual premium that you pay?

Trade (e.g. Architects, IT)

When was the business established (year)?

Premises Address

Premises Type

Please select Drop Down - High Street (Residential above) High Street (No Residential above) Office Block Other

Is the office self contained?

Please select Yes No

Do you have an intruder alarm?

Please select Yes No

Do you have shutters or grilles on your premises?

Please select Yes No

Current Annual Turnover

Contents (including fixtures and fittings)

Computers

Buildings (including tenants improvements)

Business Interruption Cover

Business Interruption Cover - is cover required over 12 or 24 months?

Other (please specify)

Have you had any claims under this type of policy in the past 3 years?

Please select Yes No

If yes, please specify the number

Please select 0 1 2 3 4 5 6 7 8 9 10

Have any of these claims been settled for more than £2,500 (approx)?

Please select Yes No

Please provide any further details relating to your application (e.g. Multi tenure premises / computers or other equipment taken away from the office / ever had request for insurance declined? / has building ever been affected by subsidence or underpinned? )