Surgery Insurance Quote

1Your Details

2About the Proposer

3Surgery Buildings details

4Cover Details

5Claims Details

Your Details

Name of Policyholder *

Status of Policyholder *

Date Company established (if applicable)

Name of Contact *

First

Last

Your Contact Number *

Email *

Has the Proposer(s), or any Partner(s) or Director(s) ever been:

a) convicted, cautioned or currently have any prosecutions pending against them regarding any criminal offence, other than a motoring offence? *

b) refused insurance, had special conditions imposed by an Insurer, had any insurance terminated or been refused renewal of such insurance? *

c) declared bankrupt, or had a company become insolvent or voluntarily gone into liquidation or Compulsory liquidation? *

d) disqualified from being a company director? *

Business Type *

How long have you owned the property? *

Postcode & 1st line of the address of the building: *

Year of Build *

Are you insuring the whole building?: *

If No, which part of the building are you insuring?

Surgery Buildings Insurance

Is the Building constructed only with walls built of brick, stone or concrete? *

Does the Building have a roof constructed only of slate, tile, metal or concrete? *

if no, please provide details:

What percentage of the roof is flat (0-100%)? *

What is the construction of the flat roof if there is one (ie. felt on timber)? *

How many floors are there (including any basement)?

Is the building subject to a preservation order?

Has the property suffered from, or shows any visible signs of damage from subsidence, landslip or ground heave? *

Is the Building heated by FIXED Gas, Electric or Oil Central Heating? *

Do you have a sprinkler system *

Have you had a fire risk assessment *

Have you had your electrical installations tested *

Are the premises protected by an intruder alarm? *

Is the alarm maintained under a contract *

Are the premises within a covered and locked shopping centre or mall that is partolled by security guards or grilles? *

Are bars fitted to all easily accessible rear and side windows? *

Is there a residential section to the property? *

Are the premises occupied overnight by the proposer or a family member or employee of the Proposer? *

Are the premises more than 25 metres away from the nearest river, canal, lake or tidal waterway? *

Description of neighbourhood

What is the Declared Buildings Sum Insured (the lower one on your present schedule if you have one or the cost to rebuild your property)?

Is cover required for subsidence? *

Cover

Please confirm value of stock

What level of cover do you need for all other Contents

Please key in requred limit for Computer Equipment, if required

Please key in required limit for Business records, if required

Please key in the tenants improvements sum insured, if required, otherwise leave blank

Please key in the required limit for money on the premises during business hours, in transit or held in a bank night safe until removed by a bank official if required, otherwise leave blank

Please key in the required limit for money contained in a locked safe outside business hours if required, otherwise leave blank

Do you require cover for loss of rent? *

Do you need Employers Liability Cover - £10,000,000? *

Do you need Public Liability Cover - £5,000,000? *

Do you require Legal Expenses Cover? *

Is Terrorism Cover required? *

Is Employee dishonesty cover required? *

Claims

Have you ever had any claims or incidents at these or any other premises in the last 5 years?: *

If yes please provide details of Date/Loss Type/Cost

Date of renewal

Name

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Surgery Insurance Quote

Your Details

Has the Proposer(s), or any Partner(s) or Director(s) ever been:

Surgery Buildings Insurance

Cover

Claims

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