Please Complete Your Details Below  – Same Day Cover Available!

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N.B. Please state if the property owner is an individual, partnership, limited company etc


Please carefully review the Statement of Fact below and advise if you do not agree with ALL of the statements:

A. No partner, director or any other person responsible for the property which is the subject of this insurance proposal, or any other business in which you, or they, have been trading:
1. Have any convictions, criminal offences or prosecutions pending, other than motor offences, or received an official caution within the last three years
2. Have been declared bankrupt/insolvent, or the subject of bankruptcy proceedings
3. Have been officers of a company that has been declared insolvent, or had a receiver, administrator or liquidator appointed, or entered into arrangements with creditors in accordance with the Insolvency Act 1986 or any subsequent legislation
4. Have been the subject of a county court judgement (CCJ) in respect of debt, either as private individuals or in connection with any business
5. Have been the subject of a recovery action by Customs and Excise or the Inland Revenue
6. Have been disqualified under the Company Directors Disqualification Act 1986 or any subsequent legislation
7. Have had a proposal refused or declined or ever had an insurance cancelled, renewal refused, a claim repudiated or special terms imposed
8. Have been officer of a company subject to Prohibition or Enforcement action by any regulatory bodies or been served with a prohibition or improvement notice

B. The property:
1. Is of non-combustible construction with no composite panels
2. Is not built on made up ground
3. Is not located in an area with a known history of subsidence; has no visible cracks; and the property or any adjacent property has not previously suffered from any subsidence, heave or landslip
4. Is not in an area previously affected by flood
5. Does not have any high risk adjoining or neighbouring premises
6. Is maintained in a good state of repair

C. You comply with the requirements of the Regulatory Reform (Fire Safety) Order 2005 (or any similar, equivalent or subsequent legislation) and UK health and safety legislation

D. All Material Facts have been disclosed

Once you have carefully reviewed the Statement of Fact, please Select from the options below:





Scope of Insurance Cover - Please Select from the Additional Cover Options Below

N.B. Terrorism cover may need to be quoted as a separate policy


Sums Insured

i.e. the total cost to re-build the premises, including debris removal and professional fees, not the market value of the property

i.e. floor coverings, light fittings etc and other property owned by the landlord that don't form part of the building 

If Employers Liability cover is required, please provide details of the estimated annual wages / payments to labour only subcontractors below and confirm the number of employees:


Claims / Loss Experience (irrespective of whether a claim has been made)