Quotation Request xxx Office and Surgery Package Direct Client Details Property Details Security The Business Sums Insured Additional Package Benefits Liabilities Commercial Legal Expenses Claims Statement of Fact Broker Requirements Cover Details Notes Documents Only Excess Survey Client DetailsIs this a Renewal Yes No Cancellation Reason INTRODUCTORY STATEMENT: It is important that the information provided throughout the quote is accurate and complete. Failure to disclose correct and complete information may result in increased premiums, refusal of a claim or it not being fully paid, your policy being cancelled or being made null & void and treated as if it never existed. Approved by System Mark Williams Lucas Benson Becky Plumb Paul Godfrey James Smith Ben Harrington Roger Hawkes Michael Sharkey Sarah Smith Stef Russell Kirsty Smith Kieran Wilkinson Carrie Shaw Daniel Beardwell Neil Aldred Paul Neary Rahim Ali Kerrie Saunders Proposer/Company Name Trading Name(s) Account set up details (these will be used later to retrieve saved quotations or policy documents) Email you will log in with this Forgot your password? Email enter again Password Password enter again Phone number What is the renewal or expected start date of this policy 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2024 Correspondence Address UDPRN Organisation Line 1 Line 2 Town/City County Postcode Enter address manually or Enter address manually Use address lookup Please select one or more trades / occupations carried out at the premisesClick the green plus button below to add another trade Trade - select - AccountantAdministration Office for Construction CompanyAdvertising AgentAircraft DesignAircraft SurveyingArchitectBaby Sitting AgencyBailiffBankBuilding SocietyBusiness ConsultantCalculating ServiceCheque Cashing AgencyChiropodistClerical DutiesCommercial ArtistCommodity BrokerComputer Advisory ServiceConsulting EngineerCorrespondence SchoolDating AgencyDebt CollectionDebt ManagementDentistDetective Agency DoctorDraughtsmanEmployment Agency - ClericalEmployment Agency - ModelEmployment Agency - MusicalEmployment Agency - SecretarialEmployment Agency - TheatricalEmployment AgencyEmployment ConsultantEscort AgencyEstate AgentFisheries ConsultancyGeneral AdvertisingHire Purchase Home TutorsIncome Tax ConsultantInsurance IntermediaryIntroduction/Dating AgencyInvestment BankingInvestmentLoss Assessor/AdjustorManagement ConsultantMarine BrokingMarket Research ConsultantMarketing And Advertising ConsultantMerchant BankingMini Cab OperatorMining ConsultancyModelling AgencyMoney DealingMoneylendersMortgage BrokerNotaryOff Shore SurveyorOpinion Poll AdministratorsOsteopathPipeline ConsultantPolitical Party Private Hire OfficePrivate InvestigationRefuse Treatment ConsultancySecretarial AgencySelf Drive HireSheriff OfficersShip BrokingShipping AgentSite InvestigationSoftware EngineeringSoil EngineersSolicitorSports PromotionStockbrokerStocktakerTax OfficeTaxi OperatorTheatre / Ticket AgentTimeshare OperatorsTour OperatorTourist InformationTranslatorTravel AgentTuitionValuerVeternary SurgeonWelfare OrganisationYouth Counselling Service OccupationDiscount £ Does your actual trade differ from the ones selected above? Yes No Please provide a full business description PostcodeNoSpace PostcodeIPTCheck Is this a CIA binder Renewal ?Question not used anymore, new renewal question added 22/05/2017 Update docs before deleting question Yes No Property DetailsIs the insured address the same as the correspondence address Yes No - select - Insured Address UDPRN Organisation Line 1 Line 2 Town/City County Postcode Enter address manually or Enter address manually Use address lookup How many full years have you been trading at these premises Is the premises self contained with its own lockable entrance door? Yes No - select - Please provide details in the space below Construction of the Floor? Concrete Wood Other - select - Please provide details of the floor below Is the premises built entirely of brick, stone or concrete and composed only of non-combustible materials? Yes No - select - Please provide details of the construction Is the premises roofed entirely with slates, tiles, concrete or metal, and composed only of non-combustible materials? Yes No - select - Please give details of the roof construction Is the property in a good state of repair?A property in a good state of repair is fit for human habitation in accordance with all health codes. Everything operates as it should and the property is clean and well maintained inside and out. There is no wasting or neglect of the property going on.one without structural problems. Your property is not considered to be in a good state of repair if it has dry rot, rot or infestation requiring timber or window replacement, damp, roof or chimney stack damage, faulty wiring or incomplete construction. Yes No - select - Please provide details in the space below Is any part of the roof constructed of flat felt on timber? Yes No - select - What percentage of the overall roof is constructed of flat felt on timber? Less than 10% 10% to 25% 26% to 50% 51% to 75% 76% to 100% - select - Is the premises Free from and in an area which is free from any signs of subsidence, heave or landslip both now and in the past. Yes No - select - Please provide details in the space below. Is the premises in an area which is free from flooding and at least 250 metres away from the nearest lake, river, canal or tidal waters. Yes No - select - Please provide details in the space below SecurityIs the premises fully occupied solely by the business? Yes No - select - Please provide additional information in respect of the above Is the premises ever vacant for more than 14 consecutive days at a time? Yes No - select - Please provide additional information in respect of the above Is the premises occupied over night ie. Proposer/Manager living above, 24hr Security. Yes No - select - Please provide details of any overnight Security Is the premises situated in an office block or modern enclosed shopping centre? Yes No - select - Is the premises protected by any of the following: Fire Alarm Yes No - select - Sprinkler Installation Yes No - select - Do you have a CCTV system present and monitoring the premises? Yes No - select - Please select the type of CCTV system used: Live Monitors - 24 hours Live Monitors - Day only Live Monitors - Night only Recorded only - 24 hours Recorded only - Day only Recorded only - Night only Other - select - Please provide additional information in respect of the above Intruder Alarm Yes No - select - Signalling Method Grilles, bars or shutters fitted to a shop front and all ground floor windows? Yes No - select - Are all external doors at the premises and any internal doors leading to other premises secured by mortise deadlocks and box striking plates which conform to current British Standard 3621 specification?Any door or window officially designated a fire exit by the fire authority is excluded from this condition. Yes No - select - Please provide details of locks protecting the final exit doors Are all accessible windows and all fanlights and skylights fitted with key operated locks or screwed shut? Yes No - select - Please provide details of the security protecting accessible windows, fanlights and skylights. The BusinessIs any part of the premises subject to any contract with or let to students, any government department, local authority, housing association or other similar organisation, any person who is seeking but has not yet been granted asylum in the UK or, any person where the premises or any identifiable person thereof will be solely occupied by the above and do you offer leases under 6 months? Yes No - select - Please provide details Interested Parties Are there any Interest Parties to be noted against this premises?The will enable you to note the mortgage company and there reference. Some mortgage companies insist there name being noted on the policy. Yes No - select - Please provide details of one or more interested parties belowClick on the + or - to add or remove an Interested Party NameAddress Line 1Address Line 2TownCountyPost CodeRef Sums Insured Basic Cover Buildings (Total estimated rebuild cost) £ . Buildings Level 1 - £0+ £ . Buildings Level 2 - £100,001+ £ . Buildings Level 3 - £150,001+ £ .Buildings Level 4 - £250,001+ £ . Buildings Level 5 - £500,001+ £ Include Subsidence Cover? Yes No Tenants Improvements £ Computers and ancillary equipment (including Laptops) £ Computers and ancillary equipment - Business Interruption £ General Contents £ . Contents Level 1 - £0+ £ . Contents Level 2 - £20,000 £ . Contents Level 3 - £40,000 £ . Contents Level 4 - £60,000 £ . Contents Level 5 - £80,000 £ Material Damage and BI Total Exposure £ Buildings Code Contents Code Amlin Minimum Premium £ Oxygen Minimum Premium £ Buildings Maximum £ Contents/Stock Maximum £ Crime Subs Flood Arson Terror Buildings Survey Requirement £ Subs Load - Buildings Subs Load - Contents Subs Load - BI Total Premium £ Alarm Level Alarm Level Required DiscountNeeded £ Alarm Level Required - Target Stock Alarm Level Required - Tobacco Alarm Level Required - Electronic Business Equipment Alarm Level Required - General Stock Refer Amlin Refer OIM Additional Package BenefitsDo you require cover for Accidental Damage Yes No Is theft cover required? Yes No Business Interruption £ Business Interruption Basis of Settlement Loss of Gross Revenue Additional Cost of Working - select - Please state the Business Interruption Indemnity Period required 12 months 18 months 24 months - select - . BI Included £ . BI Rated £ Outstanding Debit Balances £ . Debit Balances Included £ . Debit Balances Rated £ ANNUAL Loss of Rent (Payable/Receivable) £ Please state the loss of rent indemnity period required 1 Year 2 Years 3 Years - select - Money in premises during business hours, in bank night safe or in transit£2,000 Money in premises during business hours, in bank night safe or in transit is included in the cover. If you require more than this please enter the whole amount here. £ . Money In Transit Included £ . Money In Transit Rated £ Money in safe outside of business hours£2,000 Money in safe outside of business hours is included in the cover. If you require more than this please enter the whole amount here. £ . Money In Safe Included £ . Money In Safe Rated £ Please provide Make and Model of the Safe: Property removed from the premises ItemLocationSum Insured - select - Laptop Computer & ancillary equipmentMedical or Veterinary equipmentMobile Phones & other communication equipmentOtherSurveying and monitoring equipmentVideo/Audio/Photographic equipment - select - EuropeUKWorldwide £ Do you require cover for personal accident? Yes No - select - Please provide details below of all employees to be covered under the personal accident section NameDate of Birth 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Do you require cover for Fidelity? Yes No Fidelity Premium £ Do you require cover for Terrorism? Yes No - select - Terrorism - Material Damage £ Terrorism - Business Interruption £ Personal Accident Premium £ LiabilitiesEmployers Liability limit required. Nil £10,000,000 Is your business registered in the UK, employing 1 or more People and operating a PAYE scheme?It is compulsory for all companies (including any subsidiaries) required to hold Employers Liability insurance to provide their Employers Reference No. or employers PAYE Reference. Please Click here to see an ELTO Guide for Employers. Yes No (exempt) Yes, but ERN details are not available at this time - select - Reason for exemption What is the company's Employers Reference Number (ERN)? This may be referred to as the Employer's PAYE Reference.UK businesses employing one or more people are required to have and ERN (Employer’s Reference Number, also commonly referred to as the ‘Employer PAYE Reference’), which is a unique reference number for your employee’s income tax and national insurance contributions. You will find your ERN printed or written on mandatory documents including the P45, P60, P11/D and on most payslips. / Does this policy cover more than one company? Yes No - select - Please provide details below of additional companies insured under this policy: Company NameERN / PAYE RefPrincipal or Subsidiary CoAddress - select - PS Public/Products Liability limit required Nil £1,000,000 £2,000,000 £5,000,000 £10,000,000 - select - Premium Basis - EL Minimum & Deposit In Full Per Capita EL Premium £ Premium Basis - PL Minimum & Deposit In Full Per Capita PL Premium £ PL Increase £ Is there any work away from the premises other than collection and delivery? Yes No - select - What is your estimated annual Turnover? £ Wage-roll - Staff working away from your premises £ Wage-roll - Staff working at your premises £ Commercial Legal Expenses Policy CoverOur Office Package automatically includes a Legal Expenses policy covering the following: Employment Disputes Employment Compensation Awards Employment Restrictive Covenants Tax Protection Property Legal Defence Compliance & Regulation Statutory Licence Appeals Loss Of Earnings Employees' Extra Protection Crisis Communication Contract & Debt Recovery Please Click here to see the Gold Essential Legals Summary of Cover. Do you require cover for Legal Expenses? Yes No Legal Expenses Premium £ ClaimsHave you or any of your Partners or Directors in connection with any business which you/ they have been involved had any losses whether insured or not or had any claims made against you? Yes No - select - Please provide details of all claims below Type of LossDate of LossAmount of LossClaim StatusClaim Details - select - Accidental DamageBusiness InterruptionDeterioration of StockEmployers LiabilityEscape of WaterFire or ExplosionGoods in TransitLoss of LicenceOtherPersonal AssaultProducts LiabilityProperty DamagePublic Liability - Bodily InjuryPublic Liability - Property DamageStorm or FloodSubsidenceTerrorismTheft 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2019 2020 2021 2022 2023 2024 £ - select - OutstandingRejectedSettledWithdrawn Statement of Fact Have you or any of your Partners or Directors either personally or in connection with any business which you/they have been involved ever :- been declared bankrupt or are the subject of any current bankruptcy proceeding or any voluntary or mandatory insolvency or winding up procedures? Yes No - select - been disqualified from being a Company Director? Yes No - select - had a County Court Judgement or Sheriff Court Decree? Yes No - select - ever been convicted of or charged with (but not yet tried) a criminal offence other than a motoring offence or a spent conviction in accordance with the "Rehabilitation of Offenders Act 1974"? Yes No - select - been prosecuted or have prosecutions pending under the Health and Safety at Work Act or any other statute or regulation? Yes No - select - had any insurance proposal declined, renewal refused, had any special or increased terms applied, had insurance cancelled mid-term by Underwriters, had a policy declared void or claim repudiated? Yes No - select - If you have answered YES to any question above, please provide additional information If you wish to disclose any additional information that you feel may be important to an underwriters’ assessment of this risk please do so below:NB: This WILL appear on documents I confirm that I have fully read and understood: (i) the introductory statement; and (ii) the above questions and information. I have answered the questions above accurately and completely to the best of my knowledge, information and belief. If you do not tell us about changes or have provided incorrect information, the wrong terms and conditions may be quoted and we may be entitled to: • reject payment of a claim or a payment could be reduced, or • revise the premium and/or change any excess, or • revise the extent of cover or terms of this insurance. In some circumstances your policy might be invalid, and you may not be entitled to a refund of premium Please confirm the above statement Broker RequirementsPlease provide a target premium if you have one £ Do you wish to charge an additional policy fee (This will be added to the quote/schedule) £ Cover DetailsClaims 1yr Count £ Claims 1yr Amount £ Claims 2yr Count £ Claims 2yr Amount £ Claims 3yr Count £ Claims 3yr Amount £ Claims 4yr Count £ Claims 4yr Amount £ Claims 5yr Count £ Claims 5yr Amount £ Fire Claims 5yr Count Fire Claims 5yr Amount Storm Flood Claims 5yr Count £ Storm Flood Claims 5yr Amount £ Theft Claims 5yr Count £ Theft Claims 5yr Amount £ EOW Claims 5yr Count £ EOW Claims 5yr Amount £ ThreeYrLossRatio £ Set Rate Increase Load @ % £0.00 Set Discretionary Discount @ % £0.00 Set Claims Discount @ % £0.00 Set Voluntary Excess Discount @ % £0.00 Set Occupation Discount @ % £0.00 Set Occupied Overnight @ % £0.00 Set Alarm Discount @ % £0.00 Set Minimum Net Load £ £0.00 Set Liability Adjustment £ £0.00 Set Liability Adjustment OIM @ % £0.00 Set Minimum Net Load £ £0.00 Set Rate Increase Load @ % £0.00 Set Discretionary Discount @ % £0.00 Set Mesothelioma Load @ % £0.00 Set Claims Discount @ % £0.00 Set Voluntary Excess Discount @ % £0.00 Set Occupation Discount @ % £0.00 Set Occupied Overnight @ % £0.00 Set Minimum Net Load £ £0.00 Set Rate Increase Load @ % £0.00 Set Discretionary Discount @ % £0.00 Set Mesothelioma Load @ % £0.00 Set Claims Discount @ % £0.00 Set Good Practice Discount @ % £0.00 Set Voluntary Excess Discount @ % £0.00 Set Occupation Discount @ % £0.00 Set Occupied Overnight @ % £0.00 Set Minimum Net Load £ £0.00 Set Rate Increase Load @ % £0.00 Set Minimum Net Load £ £0.00 Total Premium (Net) £0.00 + IPT @ % £0.00 + Policy Fee £ £0.00 Total Premium £0.00 Total Commission £0.00 (Due From Broker) £0.00 Additional Notes - These do not appear on any documentationAdditional NotesPlease note: Only add information that is not covered in any questions as entering information here will trigger a referral. Documents OnlyBroker address to appear on documents Contact email address for Scheme Policy prefix to show on Documents Broker telephone number to show on documents Broker FSA Number to show on Documents OxygenWording Oxygen Ref ARAG Gold Wording ARAG Gold Cert Ref ARAG Voucher Code Policy Status (Do not change) MD Insurer (do not change) Liability Insurer (do not change) Legal Insurer (do not change) InceptionDateForDocReferences Index Linking Date Amlin Index Linking - Contents Amlin Index Linking - Buildings Oxygen Index Linking - Contents Oxygen Index Linking - Buildings ExcessLiability Excess Type 3rd Party Property Damage 3rd Party Property Damage and Bodily Injury Public/Products Liability Public/Products/Employers Liability 3rd Party Property Damage Excess 3rd Party Property Damage for Endorsement Material Damage Losses Excess£100 = 0% Discount £500 = £2.5 Discount £1,000 = 5% Discount 100 500 1000 Amlin Trade Code OIM Trade Code Significant Exclusions NoteThis will only appear on the First premium covering Letter. It does not appear on Quote or Schedule documents AR on Specified Items Excess Computer Breakdown Excess Employers Liability Exess Fire Excess Glass Excess Excess Legal Expenses Excess Products Liability Excess Public Liability Excess Storm Or Flood XSupdated by quotation rules - Need to: Update rule when OnCover works, or delete when get response to ticket 7941 Subsidence XSupdated by quotation rules - Need to: Update rule when OnCover works, or delete when get response to ticket 7941 Theft Excess Survey InfoCurrent Year OnlyDid this risk require a Survey this year ? Yes No Survey FeeThis fee will be set to £0 on any MTA or Renewal £ List any Survey Details for previous years Date of SurveyReason for SurveyAny Info 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2024