PROPOSER DETAILS
Contact Name - Title & Surname:
Contact Name - First Name:
Company Name (if applicable):
Contact Number:
E-mail Address:
Renewal Date:
Target Premium (£):
PROPERTY DETAILS
Risk Address:
Postcode:
Approx. Date Property Built:
Description of Property:
Business Activities of Former Tenant(s):
Business Activities of Prospective Tenant(s):
Will the Property be Owner Occuped?:
Occupancy Status:
Details if OTHER:
Details of Security Measures in Place:
COVER REQUIRED
Buildings Sum Insured (£):
Is Subsidence Cover Required?
Property Owners Liability:
Landlords Contents Sums Insured (£):
Employers' Liability:
STATEMENT OF FACT
Comments
CLAIMS/LOSSES
Please details of ALL and ANY losses you have suffered or claims you have made in the last five years (please advise date(s), cost(s) and circumstances:
Any Additional Information/Comments:
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