Commercial Combined Enquiry Form
Please complete the enquiry form below and click submit or alternatively call us for assistance on 023 8026 9009
or Corporate Title
Employer Reference Number (ERN)
(If more than one trading name you must provide the different ERN’s)
Address Line 2
State / Province / Region
Postal / Zip Code
Address of Property to be insured (if different from above)
Address Line 2
State / Province / Region
Postal / Zip Code
Full Description of trade or business
When was the Business Established?
Premises occupied as (e.g. offices, factory, warehouse etc)
1 - Material Damage
If not required please proceed to section 2
Do you require ‘All Risks’ cover?
Do you require Cover for named Perils?
Please state values to be insured:
a) BUILDINGS, including Landlord’s fixtures and fittings therein and thereon
b) TENANTS Improvements & Internal Decorations
c) RENT on the buildings
d) STOCK including MATERIALS IN TRADE and GOODS IN TRUST or on commission for which you are responsible
e) WINES, SPIRITS, TOBACCO AND/OR CIGARETTES
f) MACHINERY. PLANT, FIXTURES & FITTINGS & ALL OTHER CONTENTS including office machinery, furniture and the like
g) COMPUTER & ANCILLIARY EQUIPMENT
2 - Business Interruption
If not required please proceed to section 3
Sum insured GROSS PROFIT including Payroll and Auditors Fees
Indemnity period required
Please advise payroll element in Gross Profit sum insured
If loss of Book Debts cover required please answer the following questions:
Sum Insured required
Are books of account and records kept in a fire -resisting safe when not in use?
Are duplicate records kept?
If NO, can the amount of outstanding debts be re-created from other sources
3 - Liabilities
If not required please proceed to section 4
Employers Liability included at £10,000,000
If cover is required for Products Liability please list products (in general terms) produced or supplied and state whether any of the products are exported to the U.S.A or Canada either directly or indirectly.
Do you undertake work away from your own premises?
If YES. Please state nature of work and approximate percentage of turnover or employees wages (state which) related to work away:
Have you ever been prosecuted for any breach of the Factory Acts, or the Health and Safety at Work Act?
If YES, please give details and date of the offence:
State total estimated wages for the forthcoming year in respect of the following:
a) Clerical and non-manual employees
b) Wood-working machinists
c) All others (please describe)
d) Payments to Labour Only Sub-Contractors
Public and Products Liability
State total estimated turnover for the forthcoming year in respect of:
Other Counties - Please specify below
d) Rest of the World
Health and Safety
Is your business a commercial (non- retail), industrial or contractors risk with more than 5 employees?
If YES please answer the following questions otherwise skip to the next section
Do you have a Health and Safety Policy in force and up to date?
Have you carried out the following assessments in respect of the Management of Health and Safety At Work Regulations 1999? (If applicable to the type of business)
a) manual handling
c) working with machinery
d) work at height
Do you record in document form for the above risk assessments
4 - Glass
If not required please proceed to section 5
State total value of glass to be insured
State the value if any special glass (bent, lettered, embossed etc) is included in the insured figure.
State measurements of glass to be insured
5 - Money
If not required please proceed to section 6
State estimated total carryings per annum (including all transits TO and FROM the Bank or Post Office, collections and deliveries TO and FROM other offices and clients etc).
Cash and Bank Notes
Cheques and Other Negotiable Documents
State limits required:
In transit or on premises during business hours or in a bank night safe
In locked safe on premises out of business hours
At Residences of Directors and Senior Employers
Have you a safe on the premises
If yes, please give details e.g. make and model, size, weight, how secured to floor, whether Fire and Burglar resistant
6 - Goods In Transit
If not required please proceed to section 7
State limit required for any one vehicle
State limit required for any one loss
State total value of goods carried during the year for the following:
a) By your own vehicles
b) By public hauliers
c) By other methods (Please state)
7 - Loss of Liquor License
If not required please proceed to section 8
State the sum insured
Have the premises been closed during normal licensing hours in the last 12 months
Within the last 5 years has there been any opposition to the grant, renewal or transfer of the license; Any notice, caution or other complaint given or made against the house or any tenant; Or any conviction of any licence holder?
Has there been any disqualification or other circumstance or accident which might prejudicially affect the licence or likely to prevent the renewal thereof being obtained
Is there any intention to apply for a transfer of the licence within the next 12 months
If yes to any of the above, please give details:
8 - Deterioration of Food
If not required please proceed to section 9
State in respect of each refrigerator or cabinet
9 - General Questions - Must be Answered
Give brief description of the premises to be insured:
Construction of buildings, other occupants, processes carried on etc:
Please provide full details of protections to ALL external doors & windows (including display windows)
Is an intruder alarm installed?
If YES is the alarm
Central Station (Digital Communicator)
Central Stn (Red Care)
a) Have any of the buildings been subject to subsidence, landslip or heave damage?
b) Have any of the buildings been underpinned to prevent or repair such damage?
If YES to either question please provide full details.
How long have you been in business at these premises?
How many days a week are the premises open?
What are the normal working hours?
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
Give details of all incidents, losses and/or accidents sustained or claims made against you, for all sections for which insurance is proposed:
Are there any additional facts affecting any section of the proposed insurance which should be disclosed to the Insurers? If yes please give full details:
Period of Insurance - 12 months commencing from:
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.
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