EmailMe Form - Charity Insurance Enquiry Form

Name of Charity or Community Group

Charity Number

Telephone Number

Email address

Contact Name

Correspondence Address

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

Address of Premises
(if applicable)

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

Construction Details

If buildings or contents cover is required

Walls

Brick or Stone

Other (Please provide further details)

Roof

Tile or Slate

Other (Please provide further details)

Please describe the construction of the premises

Approximate percentage of roof which is flat

Construction of flat roof

Concrete

Felt on Timber

Other (Please provide further details)

Approximate year built

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

Yes

No

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

Is your section of the property self-contained?

Yes

No

Is an alarm fitted at the premises?

Yes

No

If so, please confirm the name of the alarm installer (normally shown on the external box) and the type of signalling, e.g. bell only or central station.

Details of Additional Security

Sums to be insured

Rebuilding value of buildings (if required)

Tenant’s Improvements (if no buildings cover)

Annual rent payable

Computers and electronic equipment

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 including anything that is unusual or could be relevant to insurers:

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.