Healthcare-ff

Contact name:

Phone:

Email:

Correspondence address: (If it is different from the address being insured)

Insurance renewal date or policy start date

Current Insurer:

Premium:

Business Name

Trading name

Status of entity

Company registration number

If applicable

How many Directors and/or Partners the business has in total?

1) Full name / Date of Birth / Position within the company:

2) Full name / Date of Birth / Position within the company:

3) Full name / Date of Birth / Position within the company:

4) Full name / Date of Birth / Position within the company:

Select any of the following that apply to your business or any Director or Partner:

had any convictions or criminal offences which are not spent under the Rehabilitation of Offenders Act or have any prosecutions pending
been declared bankrupt or insolvent or been the subject of bankruptcy proceeding or insolvency proceeding
been served with prohibition or improvement order under health and safety regulation
been the subject of a recovery action by Customs and Excise or the Inland Revenue
been disqualified from holding company directorship
Have CCJ's and Sheriff Court Decrees
Not applicable

Select any of the following that apply to your business or any Director or Partner:

had insurance cancelled
had a proposal refused or declined
had a renewal refused
had special terms imposed
None

Business description

Date business established

Business Turnover (next twelve months) (£)

Does the business have any employees?

Total number of employees?

How many of the employees are manual workers?

Estimated wageroll for manual workers (£)

How many of the employees are clerical, admin and other

Estimated wageroll for other workers (£)

Employer PAYE No

Are any employees paid below PAYE threshold?

(inc. LOSC, trainees, apprentices)

Business Premises address (Property Name, Building Number, Street Name, Town, Post Code)

Property type:

When the property was built:

Business hours:

Are there any other occupants that use the premises?

Please specify tenants types:

Is the property listed?

Please specify:

Is the business self-contained with its own means of access?

Is the property in area with history of flooding?

Is the property of non-standard construction?

[walls not built only of brick, stone, concrete or roofed only with slates, tiles or concrete]

Is there an ATM on the premises?

Is the premises in a good state of repair and free from damage?

Number of storeys where floor is of concrete construction:

Number of storeys where floor is of wooden construction:

What materials are the property walls made of?

Please provide percentage split, if the walls are made of more than one material

What materials is the property roof made of?

Please provide percentage split, if the roof is made of more than one material

Is there an area of flat roofing?

Please state the approximate percentage of the roof being flat:

Does the business also own the building?

Date of purchase:

Name of the person holding the ownership on the Land Registry Title Deeds?

Please select all the Risk Management Features that are currently active for this property:

Wired Fire Alarm
Fire extinguishers
Sprinklers
Intruder Alarm
Electrical installation inspected regularly
Trade waste managed and disposed of correctly
Town Centre / Local Authority CCTV
Computer record back-up & off-site storage
Maintenance Programs in Force
Electrical appliances inspected regularly
Business Continuity Plan
None

Is the intruder alarm maintained by accredited company?

The name of contracted accredited company for the alarm:

What type of signalling your alarm has?

Redcare
Digicom
Bells only
Other

Is the alarm connected to the Police response?

Are your sprinklers maintained by Loss Prevention Certification Board approved company?

Sprinklers accreditation details:

Heating type:

Heating fuel type:

What type of Security Aids does the business use?

Private CCTV with 30 days recording facilities
Town Centre / Local Authority CCTV
Access Control
Shutters
Window bars
Security patrols
Guard dog
Proposer/family members or employees living above
Other
None

Please specify:

Please specify type of door locks:

Please specify type of window locks:

Would you like to cover Money in Safe or Strongroom in the Premises?

What is the Safe Make? / Model ?/ Description ?/ How is it secured?

Sum of money required to be insured contained in a locked safe

Sum required to be insured, which are not in a locked safe

Sum required to be insured on premises during business hours

Sum required to be insured on premises outside business hours

What is the estimated total value of the building? (Including fixed glass, landlords fixtures/fitting)

Estimated value of the tenant improvement:

SUM INSURED:

Estimated value of the Business Fixtures and Fittings:

Estimated value of the Electrical Equipment:

Estimated value of the Business Stock:

Estimated value of the Computers or other professional equipment:

Please list any specified items to be insured:

Please leave it blank if not applicable

Have there been losses or incidents giving rise to a claim in the last 5 years

Claim history within the last 5 years (If applicable)

Any addition information?

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Fact find questionnaire

for surgeries & OTHER medical Facilities

FILL OUT THE FORM BELOW TO GET AN INSURANCE QUOTE

SUM INSURED: