Please complete all the details required below Business Details Title Mr Mrs Miss Ms Dr Sir Prof Reverend Councilor Dame Dean Judge Lady Lord First name Surname Address to be insured Postcode Daytime number Mobile number Email address Description of Trade/Business Years trading Trading as Your existing insurance renewal date (dd/mm/yyyy) Present Insurers Target premium How would you like to receive your quote Mobile number Daytime number Email Post Select     Building Information Is building of standard construction (Bricks, Tile, Motar etc) Yes No Select If no please give details How many storeys is the building Is the shop self contained Yes No Select Is the shop situated in a mall or multi tenure converted building Mall Multi Tenure Select Are there any residental areas above the shop Yes No Select If yes to above question are they occupied by professionals Yes No Select If the shop has a residential area, is it accessable via the shop Yes No Select Do you have a frying range installed Yes No Select If you have a frying range how old is it and what is its value     Building Security Do you have an alarm Yes No Select If you have an alarm is it a bells only alarm, Digicom, NACOSS red care Yes No Select Is your alarm maintained on a contract Yes No Select Do you have external shutters on doors and windows Yes No Select Do you have a CCTV system Yes No Select Please provide details of any other security measures you have in place.     Sum Insured Amounts For: Buildings Business equipment Machinery & own plant Fixtures & fittings Stock (Including brief description excluding items below) Tobacco, Cigarettes, Cigars Beers, wines, spirits Jewellery, Precious metals or stones Video equipment, cassettes, discs & computer or video games     Business Interruption Is cover required Yes No Select     Liability Insurance Public/Product liability Yes No Select Employers liability Yes No Select Specify limit of liability cover required 1 Million 2 Million Select     Optional Additional Cover Buildings Yes No Select If yes to above sum to be insured Refigerated stock Yes No Select Loss of licence Yes No Select Accidental damage Yes No Select Total sum to be insured for the three items listed above Total limit of indemnity required     Policy Excess Please specify amount 200 250 500 Select     Risk Assessment (1) Have you or any Director or Partner incurred any loss, destruction, or damage or had any claim against you in the last 5 years? Yes No Select (2) Do you undertake work away from the premises? Yes No Select (3) Does any other business occupy or operate from these premises? Yes No Select If the answer is yes to 1, 2 or 3 above please provide full details.

Spa Insurance Services Ltd is Authorised and regulated by the Financial Services Authority
FSA Reference number is 450429

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