EmailMe Form - Village Hall Enquiry Form

Name of Village or Community Hall

Address of Village Hall

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Contact Name

Contact Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Email address

Telephone Number

Is the organisation a registered charity?

Yes

No

If so what is the charity number?

Year established

Construction and Activities:

Walls

Brick or Stone

Other (Please provide further details)

Roof

Tile or Slate

Other (Please provide further details)

Approximate year Hall built

Is the premises a listed building?

No

Grade 1 Listed

Grade 2* Listed

Grade 2 Listed

Please provide further information in the box below

Approximate percentage of roof which is flat

Construction of flat roof

Concrete

Felt on Timber

Other (Please provide further details)

Does the premises have a key box/key safe?

Yes

No

Does the premises have any solar equipment?

Yes

No

Please clarify what equipment at the end of the form

Has the premises previously suffered from any Subsidence, Heave, or Landslip? *

Yes

No

Please also state "Yes" if you're aware of any underpinning to the foundation.

Are your premises within 500 metres of a watercourse?

Yes

No

If so, is there any history of flooding at the premises?

Please provide details of any playing field or outdoor play equipment for which you are responsible

Sums to be insured

Buildings

Outdoor play equipment

General contents

Computers & electronic equipment

Property belonging to hirers

Bar stock

Items used away from the premises

(e.g. laptop, computers, trophies, marquees)

Solar Panels or Storage Batteries

Please provide details

Money cover is automatically included at a sum insured of £2,500

Public & Property Owner’s Liability is automatically included at a £5m limit. Cover also includes Public Liability for non profit-making hirers of your premises

Employers’ Liability is included for employees and volunteers at a £10m limit

Committee Details

Number of committee members/trustees

If you are aware of any bankruptcies, CCJs or criminal convictions (other than motoring) in respect of any trustee or committee member then please provide details.

Maximum number of additional volunteers

No of employees

Duties of employees

Annual wageroll

Total annual income

Of the total annual income, what approximate percentage is from alcohol sales?

What is your Employer Registration Number? (If you have one)

Do you require Personal Accident cover for committee members?

Yes

No

Trustees Indemnity cover is normally included at a limit of £250,000. Please indicate if you require a higher amount

£250,000

£500,000

£1,000,000

Do the assets of the organisation exceed £2.5m?

Yes

No

Activities arranged by committee

Activities arranged by hirers

Committee Activities undertaken away from Hall & maximum attendance at these events

Previous Insurers

Present Insurer

Approximate Premium

Renewal Date:

DD / MM / YYYY

Where did you hear about Norris and Fisher?

Have you had any claims or incidents within the last 5 years? *

Yes

No

If yes please provide full details:

Please include a date of loss, claim settlement amount, and the type of claim (Flood/Public Liability/Fire etc)

Please declare if any Principals/Committee Members/Trustees have had any of the following: *

Previous insurance declined, cancelled or terms applied

Declared bankrupt or had any unsatisfied County Court Judgments

Convicted with or charged with or received caution for any criminal offence other than motoring that is not spent

None of the above

If you answer yes to any of the first three options, please provide further information in the box below

Further details where appropriate

Please use this box, where appropriate, to elaborate on construction details, risks or anything which may be unusual about your hall or its use

Preferred method of contact

*

I have read and agree to the terms and conditions.

Our terms and conditions can be read on our website at www.norrisandfisher.com/terms

Norris and Fisher (Insurance Brokers) Ltd complies with the requirements of the Data Protection Act (DPA) 1998 and General Data Protection Regulations (GDPR) 2018. This Act places legal obligations upon Norris and Fisher (Insurance Brokers) Ltd in respect of the way we collect, review, distribute and store personal data.

In order to assess your application and help us reach a decision, we need to process relevant personal details. By ticking this box you are giving your consent for Norris and Fisher (Insurance Brokers) Ltd to do this.