General:
Company Name:
Address 1:
Address 2:
Post Code:
Telephone No:
E mail:
Business description:
Type of Firm: Limited Company
Partnership
Sole Trader
When established:    
Annual Turnover: £
Have you had any claims in the last 5 years: Yes   No
If Yes, please give details:
Premises:
Are your premises detached? Yes   No
Are your premises in an Arcade or Shopping Centre? Yes   No
Non combustible construction? Yes   No
Do you have an intruder alarm? Yes   No
Sums Insured:
Buildings £
Stock of High Risk Items
(Cigarettes, tobacco, wines, spirits, precious metals and stones, non-ferrous metals & portable hand tools) 		£
Other Stock £
Computers & Electrical Office Equipment £
Other Business Equipment £
Frozen food £
Trade Specific Questions:
Number of letting bedrooms:
Do you have guests stopping for longer than 4 weeks? Yes   No
Number of restaurant covers:
Do you have deep fat fryers? Yes   No
Are they and associated ducting and extraction the subject of an annual cleaning contract? Yes   No
Do you provide the following entertainment:
Disco's: Yes   No
Karaoke: Yes   No
Solo/Duo artists: Yes   No
Groups and Bands: Yes   No
Childrens play areas: Yes   No
Do you charge a fee for entertainment: Yes   No
Loss of Revenue:
Do you need an indemnity period longer than 12 months? Yes   No
If 'Yes', how long    
Amount of Loss of Licence Indemnity required: £
Your name: Position: