Quotation Request Form by v6XTCxT7

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									                                      Broking Template/Statement of Fact:
                                      RESTAURANTS & PUBLIC HOUSES

 Proposer’s / Insured’s details                                               Date of Issue:

 Proposer’s Name                                                               Co. registration no.

 Website Address                                                               PAYE Ref Code (ERN)

 Proposer’s Address                                                            Town/City

 County                                                                        Post Code

 Business Description


 Other Companies Please list all and specify whether dormant, a subsidiary or associated and include any ‘Trading as’ names

 Name (and address if                                                           PAYE Ref Code (ERN)
 different from above)


 Name (and address if                                                           PAYE Ref Code (ERN)
 different from above)


 Name (and address if                                                           PAYE Ref Code (ERN)
 different from above)




 Claim Experience in past 5 years

          Date             Details (include circumstances and post loss action to prevent reoccurrence)           Amounts paid


                                                                                                          £
                                                                                                              Include any outstanding
                                                                                                               amounts not yet paid




                                                                                                          £
                                                                                                              Include any outstanding
                                                                                                               amounts not yet paid




                                                                                                          £
                                                                                                              Include any outstanding
                                                                                                               amounts not yet paid




                                                                                                          £
                                                                                                              Include any outstanding
                                                                                                               amounts not yet paid


Continue elsewhere if necessary for the disclosure of all claims.




RP 01.11.09                                                                                                                             1
                                       Broking Template/Statement of Fact:
                                       RESTAURANTS & PUBLIC HOUSES

 Description                                                                                     Sum Insured

 Buildings (if cover required)                                               £

 Tenant’s improvements                                                       £

 Electronic Office Equipment                                                 £

 Computer Equipment                                                          £

 Trade Contents (excluding stock)                                            £

 Stock of Wines & Spirits                                                    £

 Stock of Tobacco, Cigarettes, Cigars                                        £

 Stock of Video Tapes / CD's / DVDs                                          £

 All other stock                                                             £

 Any other specified property                                                £

 Business Interruption: Gross profit sum insured                             £

 Indemnity Period                                                            _________________________ Months

 Accounts Receivable                                                         £

 Loss of Licence                                                             £

 Freezer Contents                                                            £

 Employers Liability limit of indemnity                                      £

 Public Liability limit of indemnity                                         £

 Goods In Transit: limit per consignment                                     £

 Computer breakdown cover                                                        Yes / No (delete as applicable)

 Machinery breakdown cover                                                       Yes / No (delete as applicable)


 Are paying guests accommodated at the premises?                             Yes / No (delete as applicable)
 If yes, please state the number of letting bedrooms                         ___________________________________

 Is any form of entertainment provided at the premises?                      Yes / No (delete as applicable)
 If yes, please provide details & frequency:                                 ___________________________________

 Are children's play areas provided?                                         Yes / No (delete as applicable)
 (if so please include details of supervision, equipment provided, type of   ___________________________________
 flooring, means of access to area)
                                                                             ___________________________________

 Are deep-fat frying facilities used on the premises?                        Yes / No (delete as applicable)
 If yes, please describe                                                     ___________________________________
                                                                             ___________________________________
                                                                             ___________________________________
                                                                             ___________________________________




RP 01.11.09                                                                                                        2
                                     Broking Template/Statement of Fact:
                                     RESTAURANTS & PUBLIC HOUSES

 Construction of building                                                      ___________________________________
 Walls                                                                         ___________________________________
 Roof                                                                          ___________________________________
 Floors                                                                        ___________________________________

 State date of construction of the building

 Are the premises within a shopping centre?                                    Yes / No (delete as applicable)

 Does the premises/shopping centre have?: (please tick)                        Fire alarm  24 hr security  Sprinklers 

 Do the premises have an intruder alarm?                                       Yes / No (delete as applicable)
 Is it NACOSS approved?                                                        Yes / No (delete as applicable)
 Method of signalling:                                                         ___________________________________

 Are the premises occupied by the insured or employee overnight?               Yes / No (delete as applicable)

 Additional physical security:                                                 ___________________________________
 Do the premises have CCTV?                                                    Yes / No (delete as applicable)
 If yes is it:? (please tick)                                                  Monitored  Recorded 



 Do you comply with the Control of Asbestos Regulations 2006 (CAR) and
 having identified the presence of asbestos and asbestos carrying materials,
                                                                               Yes / No (delete as applicable)
 assessed the potential risks and prepared a management plan?
 Do your employees carry out any work with asbestos or asbestos carrying
 materials                                                                     Yes / No (delete as applicable)




 Give details of any other covers required or additional information below:

 _____________________________________________________________________________________________________

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 _____________________________________________________________________________________________________

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RP 01.11.09                                                                                                                 3

								
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