EmailMe Form - Food Bank Enquiry Form

Name of Organisation

Address of Food Bank

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

Contact Name

Contact Address
If different to above

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

Email address

Telephone Number

Year established

Is the organisation a registered charity?

Yes

No

Is so what is the charity number?

Construction and Activities:

Walls

Brick or Stone

Other (Please provide further details)

Roof

Tile or Slate

Other (Please provide further details)

Approximate year premises built

Approximate percentage of roof which is flat

Construction of flat roof

Concrete

Felt on Timber

Other (Please provide further details)

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 security within premises

What are your opening hours?

Sums to be insured

Buildings, including outbuildings (if required)

Food Stock

Committee Details & Activities

Number of committee members/trustees

Maximum number of additional volunteers

No of employees

Duties of employees

Annual wageroll

Total annual income

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

Do you require Personal Accident cover for volunteers?

Yes

No

Do you require Trustees Indemnity cover?
If so at what level?

Not Required

£100,000

£250,000

£500,000

Do you require cover for Fidelity Guarantee?
If so at what level?

Not Required

£25,000

£50,000

Do you require cover for Business Interruption?

Yes

No

Do you require cover for Legal Expenses?

Yes

No

Do the assets of the organisation exceed £2.5m?

Yes

No

Do you require cover for any work away from your premises?

e.g. Food collections from retailers/organisations or donation stations

Previous Insurers

Present Insurer

Approximate Premium

Renewal Date:

DD / MM / YYYY

Where did you hear about Norris and Fisher?

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 at the end of the form

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)

Further details where appropriate

Please use this box, where appropriate, to elaborate on construction details, claims or anything which may be unusual about your organisation or operations

Preferred method of contact

*

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.