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Risk Questionnaire for Shops and Stores
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Name of the person providing information within this form
Position held within the business
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Email
Phone
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PROPOSERS DETAILS:
How many Directors and/or Partners the Proposer have in total?
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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
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Select any of the following that apply to any Proposer, Director or Partner:
had any losses or incidents giving rise to a claim in the last 5 years
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
had a proposal refused or declined
had an insurance cancelled
had a renewal refused
had special terms imposed
been the owner or director of, or partner in, any business, company or partnership had a county court judgment awarded against them
been disqualified from holding company directorship
been served with prohibition or improvement order under health and safety regulation
been convicted of (or charged but not yet tried for) any offence other than a driving offence
been the subject of a recovery action by Customs and Excise or the Inland Revenue
had CCJ's and Sheriff Court Decrees
Not applicable
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BUSINESS DETAILS:
Business, Company or Partnership Name:
Trading name
Status of entity
Please choose from the drop down list:
Limited
Partnership
Private
Public Limited
Sole Proprietor
Religious Organisation
Charity
Association
Club
Community Group
Community Interest Company
Voluntary Organisation
Incorporated
Limited Liability Partnership
Local Authority
Public sector
Self Employed
Society
Trade Union
Trust
Company registration number
Are you VAT registered?
Yes
No
VAT number
Business description
Date business established
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Correspondence address:
Post code:
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EMPLOYMENT AND TURNOVER DETAILS:
Do you have any employees?
Yes
No
Employer PAYE No
Total number of employees?
Are all employees (inc. LOSC, trainees, apprentices) paid below PAYE threshold?
Yes
No
Estimated Wageroll (next twelve months) (£)
Estimated Turnover (next twelve months) (£)
Percentage of turnover to be derived from second hand goods?
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BUILDING AND CONTENTS
Premises address:
Post Code:
Do you own the business premises?
Yes
No
Name of ownership on the Land Registry Title Deeds?
The business premises type ie. Commercial, Industrial, Domestic
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Primary building usage?
Secondary building usage?
Is the building listed?
Yes
No
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Year the property was built?
Date of purchase
Business hours:
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MATERIAL FACTS (Please select all the relevant options)
The business is not self contained with its own means of access
The premises is in area with history of flooding
The property has walls or roofs constructed of composite panels
The property has walls or roofs containing combustible linings
The property is erected on made up ground or has been underpinned
The property has visible signs of cracks
The proposer is not the sole occupant (if other than offices or private dwellings)
The property is unoccupied, or has not been used in the last 30 days
There are trees or shrubs, which are more than 5 meters in height and within 10 meters of the property
The premises is closed for more than 3 consecutive months
The property or adjacent property has suffered from, or shows any visible signs of damage from subsidence, landslip or ground heave
The property is unduly exposed to storms or high winds
The property is close to mines/underground workings
The property is close to cliffs, embankments, railway cuttings, tunnels, quarries or other excavations
The property is close to vibrations from major roads/railways
Not applicable
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Total number of stories
Are the walls of the building made with:
One type of material
More than one type of material
Please select the building's wall material
Please choose from the list
Asbestos
Brick
Brick/Timber Frame
Cob
Concrete
Corrugated iron
Fibreglass
Flint
Metal
Plastic
Prefabricated building - Combustible Materials
Prefabricated building - Non-combustible Materials
Slate
Stone
Tile
Timber
If, yes please specify what materials and describe percentage of each material used
Is the roof of the building made with:
One type of material
More than one type of material
Please select the building's roof material
Please choose from the list
Asbestos
Asphalt
Concrete
Corrugated iron
Felt on timber
Fiberglass
Glass
Metal
Plastic
Shingle
Slate
Thatch - Fibre
Thatch - Reed
Tile
Timber
Woodwork
If, yes please specify what materials and describe percentage of each material used
Is there an area of roofing flat?
Yes
No
If yes, please state the approximate percentage of the roof being flat?
Describe the materials used for floors, staircases and internal partitions. Also, detail the type and extent of any composite (sandwich) panels used; their location in the building and the type of core material (PIR, PUR, etc.) including age and condition.
Please select the type of heating of the property?
Hot Air
Portable Heaters
Radiators - Hot water filled
Radiators - Oil filled
Night Storage Heater
Gas Central Heating
Electric Central heating
Fire - open
Fire - other
Oil Heater
Pressure Jet Heater
Radiant Panel Heater
Stove
Underfloor heating
Fixed Heaters
Wood burner
Other
No heating
Is the premises in a good state of repair and free from damage?
Yes
No
Please select the relevant option to describe area of your location
Predominately residential
Commercial
Industrial
Is an ATM located on the premises?
Yes
No
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RISK MANAGEMENT:
Please select all risk management features that are in use:
Smoke detectors
Fire Alarm
Fire Blankets
Fire extinguishers in place to scale
Sprinklers
Intruder Alarm
Electrical Installation Inspected Regularly (every 5 years)
Trade waste stored in metal containers / removed weekly
Computer record back-up & off-site storage
Maintenance Prog In Force For Building/Plant/Fire Extinguishing Apps
Employee induction programme
Business Continuity Plan
Is the intruder alarm maintained by accredited company?
Yes
No
If so, what's the name of the alarm?
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?
Yes
No
Sprinklers accreditation details:
What is your method of locking you exit door?
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Please specify type of door locks
Please specify type of window locks
What type of other security aids do you use?
Private CCTV
Other monitored CCTV
Town Centre / Local Authority CCTV
Access Control
Shutters
Window bars
Guard dogs
Security Patrols
Proposer/family members or employees living above
None
Do you have 30 days of more recording facilities on the private CCTV?
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SUMS INSURED AND FINANCIAL DETAILS:
What is the estimated total value of the building? (Including fixed glass, landlords' fixtures/fitting)
What is the estimated value of the Business Fixtures and Fittings?
What is the estimated total value of the Electrical Equipment?
What is the estimated value of the Business Stock?
What is the estimated value of the Business Frozen Stock?
Please choose preferred limit of indemnity cover that you require for Public / Products Liability
2 Milions
5 Milions
10 Milions
Extra layer
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BUSINESS INTERRUPTION COVER
Would you like to protect your business Gross Profit in case of unexpected interruption to the business?
Yes
No
What Gross Profit would you like to cover? (£)
Preferred Indemnity Period:
12 months
24 months
36 months
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MONEY COVER
Do you require to cover Money in Safe, Strongroom in the premises or in transit?
Yes
No
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Sum 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 in transit in the custody of a security company
Sum required to be insured in transit by Proposer or Employee
Sum required to be insured on premises during business hours
Sum required to be insured on premises outside business hours
What's the amount of annual cash carrying by you?
What's the amount of annual cash carrying by security company?
What is the Safe Make? / Model ?/ Description /? How is it secured?
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ADDITIONAL INFORMATION
Claim history within the last 5 years (If applicable)
Current or previous insurer
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Insurance renewal date
Target premium
Any addition information?
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