QUOTATION FORM

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PRINT THIS FORM AND FAX TO 01604 615407 OR COPY AND EMAIL TO carl@insurance-world.co.uk   Questions   Name   What is the full trading name of your business? E.g. John Smith trading as John Smith and Sons   Contact Telephone Number   Which of the following best describes your business?   Individual - self employed Individual(s) - Trading as... Partnership Company - Trading as... Company (Public or Private) Trustees for the time being When do you want cover to begin (dd/mm/yyyy)?   Current Insurer?   Renewal Premium?   Last years premium?   How many people do you employ?   Wageroll?   How many losses have you suffered, for any of the risks you want to insure within the last three years? Please provide details on a separate page, if any.       What is your estimated annual turnover?       How many complete years have you been in business?           Do you need cover for Terrorism ? Yes / No     Is the building of standard construction? (eg brick with slate roof)                   Property Details       What is the name or number of this property?       What is the FULL postcode of this property?       What is the nature of the business at this property?         Do you need cover for buildings? Yes / No     How much cover do you need for buildings £     How much cover do you need for loss in rental income? £     Do you need cover for contents? Yes / No What locks are on the premises?       Does the property have a fully operational alarm fitted by a company which is a registered member of an intruder alarm inspectorate which is UKAS accredited? If so please identify it. Yes / No   REDCARE Digital Communicator Other Please tell us how much cover you require for the following (enter amount in pounds sterling):   Gifts? £ Stock in the building, including frozen foods? £ Fixtures and fittings including tenant's improvements? £ Clothing? £ Alcohol? £ Video Tapes? £ Tobacco stocks? £ Deterioration of frozen foods? £ Loss of Alcohol licence? Yes/no Goods in transit? NIL £1,000 £2,500 £5,000 How much cover do you need for Gross Profit? £ How many months cover do you want?     12 24 36 Do you need cover for unspecified property away from the premises?     If Yes, how much cover do you need ? Yes  European Yes  Worldwide No   £1,000 £6,000 £2,000 £7,000 £3,000 £8,000 £4,000 £9,000 £5,000 £10,000 Do you need cover for legal expenses? Yes / No Employers Liability? Yes / No Public Liability? Yes / No Products Liability Yes / No