Your Name: (required)

Your Email: (required)

Contact Telephone: (required)

Address:

Legal Status:

What Products Do You Sell?:

Where Are Your Products Manufactured / Sourced?:

Annual Turnover:


Do You Export to USA or Canada?
 Yes No


If YES,what is the:
Percentage of total sales:


Value of total sales:

Are you an Amazon FBA Merchant?
 Yes No

Are the Premises protected by a NACOSS approved BT Redcare Alarm?
 Yes No

Are the Premises occupied overnight?
 Yes No

Buildings Sum Insured:

Stock Sum Insured:

All Other Contents Sum Insured:

Tenants Fixtures & Fittings Sum Insured:

In respect of ANY of the risks to which this proposal relates, has any claim been made?
 Yes No

If Yes, please give details :-

Claim 1



Date of Claim or Loss:

Brief Details of each Loss

Cost of Claim / Loss

Estimated cost of Claim / Loss Outstanding


Claim 2



Date of Claim / Loss

Brief Details of each Loss

Cost of Claim / Loss

Estimated cost of Claim / Loss Outstanding


Claim 3



Date of Claim / Loss

Brief Details of each Loss

Cost of Claim / Loss

Estimated cost of Claim / Loss Outstanding


Claim 4



Date of Claim / Loss

Brief Details of each Loss

Cost of Claim / Loss

Estimated cost of Claim / Loss Outstanding


Declaration

I/We declare that after full enquiry, the contents of this questionnaire are true and that I/We have not misstated, omitted or suppressed any material fact or information.

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