Proposer's full name(s):(enter sole trader's name or all partner's names if a partnership)
Contact name:(if different to proposer's name)
Limited company name:(if operating as a limited company)
Surgery trading name:
Trading status:
- - - - - - - Please Select - - - - - - -
Sole Proprietor
Partnership
Limited Company
Limited Liability Partnership (LLP)
Charity
Surgery address:
Surgery postcode:
Is there a different correspondence address? Yes No
Correspondence address:(if different from the above)
Description of type of surgery:(i.e. doctors surgery, dentists surgery, etc.)
Daytime telephone number:
*E-mail address:
*Please note that your email address will only be used to provide you with your quote and not for any other marketing purposes.
Have you, or any other partner or director ever been convicted of or charged with any criminal offence? Yes No
If yes, please provide details:(i.e. date of conviction, type of conviction, length of custodial sentence, etc.)
Have you, or any other partner or director ever had any county court judgements / sheriff decrees or been declared bankrupt, or involved in a company which has become insolvent or which has gone into liquidation, receivership or administration? Yes No
If yes, please provide details:(i.e. date of bankruptcy/insolvency, amount of bankruptcy/insolvency, whether discharged, etc.)
Has any insurer ever refused, declined, cancelled or imposed special terms in respect of your office insurance? Yes No
If yes, please provide details:(i.e. name of insurer, reason for refusal/special terms, etc.)
Have you, or any other partner or director ever been prosecuted or served a prohibition notice by the Health & Safety Executive? Yes No
If yes, please provide details:(i.e. date and reason for prosecution, etc.)
Can you confirm that you meet all the Statutory obligations; including fire safety, electrical inspections, Health & Safety and COSHH regulations, relating to the operation of your business? Yes No
Year Business Established
In what year was the business established? (yyyy)
If a new venture, please state the number of years previous experience (if applicable) :
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
30+
year(s)
General Information
Is the property in a good state of repair and maintained? Yes No
Will the premises ever been left unoccupied for more than 30 consecutive days? Yes No
If yes, please provide details:
Are you the sole occupant(s) of the building in which your premises are situated? Yes No
If No, please provide details of the other types of businesses that operate from the building:
Is your surgery entirely self-contained with its own separate lockable entrance? Yes No
If No, please provide details:
Construction Details
Is the building of standard construction?(i.e. brick/stone/concrete walls & tile/slate roof) Yes No
If No, please provide details:
What is the construction of the floor(s)?
Wooden Only
Concrete & Wooden
Concrete Only
Other
Number of storeys in the building?
1
2
3
4
5
6
7
8
9
9+
Approximately, what year was the surgery built? (yyyy)
Are the premises of grade listed construction?
Not Listed
Grade I
Grade II
Grade II*
Grade A
Grade B
Grade C
Approximate distance to nearest water, river, sea, etc.:(e.g. 250 metres, etc.)
Heating
Is the property heated only by gas or oil central heating, electric storage heaters, or fixed gas or electrical appliances or other forms of fixed heating? Yes No
If no, please provide details of other heating:(e.g. electric portable heaters, etc.)
Location
Location of premises:
- - - - - - - - Please Select - - - - - - - -
High Street
Office Block up to 10 Floors
Office Block with more than 10 Floors
Business Park
Covered Shopping Centre
Domestic Premises
Industrial Estate
Precinct
Subsidence / Flooding
Has there ever been any subsidence or flood damage at the premises or nearby? Yes No
If yes, please provide details:(e.g. type of damage date of damage, amount of damage, etc.)
Unoccupancy
Are any parts of the building at present unoccupied? Yes No
If yes, please provide details:(e.g. which floor(s) are unoccupied, percentage of the building unoccupied, etc.)
Claims Experience
Have you, or any other partner or director ever suffered any loss or had any claims made against you at this property or any other property in the last 5 years? Yes No
If yes, please provide claim details:(i.e. date of claim, circumstances of claim, amount claimed, etc.)
Security
Are all your external doors fitted with a minimum of 5 lever mortise deadlocks (BS3621) or equivalent? Yes No
Are all opening windows, fanlights and skylights fitted with key operated window locks? Yes No
Are all accessible windows protected by either solid steel bars or grilles? Yes No
Is the property protected by permanently manned 24 hour security? Yes No
Are your premises protected by an intruder alarm? Yes No
Is the alarm under the sole control of the business? Yes No
Who maintains the alarm system?
- - - - - - - - - - - Please Select - - - - - - - - - - -
NACOSS/NSI Approved/Accredited Installer
SSAIB Approved/Accredited Installer
Other Installer
Is the intruder alarm maintained annually? Yes No
Type of intruder alarm fitted:
Audible - Bells or Siren
Dialler - To Principals House
Digital Communicator - To Central Station
DualCom -To Central Station
DualCom Plus - To Central Station
BT Redcare - To Central Station
BT Redcare GSM - To Central Station
Does the surgery have any CCTV? Yes No
Please confirm the coverage area of the CCTV:
Internal Only
Internal and External
External Only
None
Please provide details of any other security arrangements (if applicable) :
Is visitor access during business hours controlled by either an access control system or a manned reception? Yes No
Fire Protection
Are there fire extinguishers at the surgery? Yes No
Is there an automatic fire alarm system installed at the surgery? Yes No
If yes, please confirm type of alarm signalling:
Bells Only
Bells & Central Station
Cover
Standard cover is for Fire, Theft And Special Perils.
Do you wish to include accidental damage cover? Yes No
Do you wish to include cover for terrorism? Yes No
Buildings (if owner occupied and required)
Buildings Sum Insured:(reinstatement value including outbuildings and an allowance for demolition costs, removal of debris, rebuilding architects fees, etc.)
Is cover required for subsidence, heave or landslip? Yes No
Tenants Improvements (if renting the shop and required)
Do you require tenants improvements cover?(i.e. to insure improvements you have made as a tenant to the building's fixtures & fittings such as a new counter, suspended ceiling, partitions, lighting, decorations, etc.) Yes No
If yes, please state the sum insured:
Contents
Computers Sum Insured:
Other Electronic Equipment Sum Insured:(i.e. photocopiers, telephone system, etc.)
Works of Art Sum Insured (if required) :
All Other Contents Sum Insured:(i.e. surgery furniture, filing cabinets, etc.)
Do you require Computer Breakdown cover?(provides cover for repair or replacement of computer equipmentand also reinstatement of data) Yes No
Property Away From The Surgery
Is cover required for business equipment temporarily taken away from the premises?(e.g. laptops, tablets, digital camera's, etc.) Yes No
All Risks Sum Insured(i.e. total value of property away from the premises) :
Type of property to be covered away from the premises:(e.g. laptops, digital camera's, etc. Please specify each item.)
Territorial area:
UK
Europe
Worldwide
Stock / Business Files
Trade Stock and Samples:
Refrigerated Drugs and Medicines:
Non-Refrigerated Drugs and Medicines:
Precious Metals (e.g. gold, etc.) :
Business Files & Documents:
Money
Is money cover required? Yes No
Money during surgery hours (£2,000 std. cover) :
Money outside surgery hours (£1,000 std. cover) : (kept in a locked safe)
Is Business Interruption cover required? Yes No
If yes, state the sum insured required for the annual loss of income:
Please confirm the maximum indemnity period:
12 Months
24 Months
36 Months
Do you require cover for loss of Book Debts? Yes No
If yes, please indicate the maximum amount of Gross Fees and Debit Balances outstanding at any one time:(e.g. £25,000)
Public / Product Liability Limit Of Indemnity:(£2 Million automatically included)
£1,000,000
£2,000,000
£5,000,000
Is any work carried out away from the surgery? Yes No
If yes, please provide details:(i.e. type of work carried out, No. of persons who undertake work away)
Employers Liability Limit of Indemnity:(£10 Million automatically included)
Please confirm the total number of surgery employees:
Please confirm the total annual wages of the employees:
Employers' Reference Number (optional)
Employers' Reference Number (ERN) (if available) : (e.g. 123/AB12345 or 'Exempt')
Turnover
Annual turnover:
Is cover required for theft by employees? Yes No
Are written references confirming the integrity of the employees obtained? Yes No
Is there a system whereby a least two employees check stock, money and other business records at least monthly? Yes No
Is commercial legal expenses cover required?(£100,000 limit of indemnity) Yes No
Has the business and/or its directors been involved in any legal dispute, tax investigation or any other court or tribunal action in the last 5 years? Yes No
Please provide details of the dispute including dates:
If there is any more information that you wish to disclose or cover that you require, please provide details:
You are required to make a fair presentation of the risk to insurers which means that you are required to disclose every material circumstance which you know or ought to know relating to the risk to be insured. Materially important information is any information that could influence an insurer's decision to accept your risk including the cost of your insurance. Failure to comply with the duty of fair presentation could mean that your policy is void or that insurers are not liable to pay all or part of your claim(s). By submitting this quotation you are confirming that there are no other material facts to disclose other than those shown above.
Date Cover Required / Renewal Date: (dd/mm/yyyy)
Current Annual Premium / Best Quotation: This may help us to get you a better quote.
Name of Current / Previous Insurer: e.g. Aviva, AXA, Allianz, QBE, RSA, Zurich, etc.