BusinessInsuranceQuotations.com Surgery Insurance Form 1. Your Name: 2. Address of your premises:  Post Code:            Telephone Number:  E-mail address: 3. Description of Business: 4. Date Established: 5. THE CONSTRUCTION OF PREMISES (eg: Brick walls, Mild steel roof)  Is there a partial or full flat roof?  Yes No  If "Yes" describe in detail: (size, type, construction and age) Which floor level does your business occupy? (e.g. ground, first floor, second floor, etc.) Are you the sole occupant(s) of the building in which your premises are situated?  Yes No If No, please provide details of the other types of businesses that operate from the building: Approximately, what year was the property built? Has the property ever suffered from subsidence or flood damage?  Yes No If yes, please provide details: (e.g. date of damage, amount of damage, etc.) Are any parts of the building at present unoccupied?  Yes No If yes, please provide details: Have you or any other director or partner (in this or any other trading name) suffered any loss or had any claims made against you in the last 5 years?  Yes No Date of claim: What happened: Total Payment: 9. SECURITY AND FIRE PRECAUTIONS    Are the premises fitted with -    Fire Alarm?  Yes No  Fire Extinguishers?  Yes No  Are fire extinguishers inspected annually?  Yes No  Are door locks 5-lever mortise deadlock type?  Yes No (eg Chubb locks)  Are window locks fitted?  Yes No  If you chose 'no' for any of the last two questions, please give details of what you do have for physical security. Are your premises situated within a street level CCTV area?  Yes No Buildings Sum Insured including outbuildings, rebuilding architects' fees, removal of debris, etc.: £ Tenants improvements sum insured £ Computers sum insured £ Other electronic equipment sum insured (fax, photocopiers, telephones etc.) £ Contents sum insured £ Stock of perishable goods - (breakdown below)    Drugs £  Precious metals and alloys £ All risks sum insured for property away from Surgery £ Type of property to be covered away from the office (laptops, phones, cameras etc) Current insurer: (so that we don't approach them) Current annual premium: (this may help us to get you a better quote) Renewal date /date cover required:    INCLUDED AUTOMATICALLY IN QUOTE - LOSS OF PROFITS EMPLOYERS LIABILITY PUBLIC AND PRODUCTS LIABILITY GLASS BREAKAGE MONEY GOODS IN TRANSIT Please supply me with an estimate within 105 working days. (We will attempt to meet the target, but please be aware that it does require our insurers to respond quickly as well!) Done   Please check your details, and when you are happy that all is correct, tick the 'Done' box and then click the Submit button above...