EmailMe Form - Office Enquiry Form

Contact Name

Correspondence Address

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

Telephone Number

Email

Business Details

Trading Name

Business Address

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

Description of trade or business

Description of any work away from the premises (if none state "none")

Number of Employees

Wageroll

Turnover

Employer Reference Number

ERN - provided by HM Revenue and Customs

Construction Details

Type of Premises

e.g. Single storey, shop with flat above, unit in retail complex

Are the premises self-contained?

Yes

No

Are the premises a standard Brick or Stone construction with Slate or Tiled roof?

Yes

No

If not please provide details at bottom of form

Approximate percentage of roof which is flat

Construction of flat roof

Felt on timber, concrete etc

Subsidence

Tick if not required

Subsidence cover is normally included automatically. If you do not require this cover or if the building has previously suffered subsidence, please tick this box.

Details of Security

Type of Heating

If you use portable heaters, please state how many

Sums Insured

Buildings

Shop Front / Tenant's Improvements

Electronic office equipment and computers

Other contents

All Risks items

Items used outside the premises

Please declare if any Principals/Partners/Directors 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 at the end of the form

Full details of claims within the last 5 years

Please provide details, dates and approximate costs of any incidents

Renewal Date

DD / MM / YYYY

Current Insurer

Current Premium

Additional Details

*

I have read and agree to the terms and conditions.

PLEASE INDICATE YOUR ACCEPTANCE BY CLICKING 'I HAVE READ AND AGREE TO THE TERMS & 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 signing this form, you are giving your consent for Norris and Fisher (Insurance Brokers) Ltd to do this.