Clinic Proposal Form

Specified Have you

Policyholder Information

Business or Trading Name *

Individual Name &/or Partnership Names (Including Trading Name) or Limited Company Name

What is the Business Status ? *

Limited
Partnership
Sole Trader
Other

Email Address *

Contact Number *

Full business description *

Correspondence address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Risk Address if different from above

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

If have more than one location please provide address below for both

Inception or Renewal Date *

Property Damage

Cover for your business’s material property - Please confirm sum insured required for each question

Buildings Declared Value (reinstatement / rebuild cost)

Only complete this section if you require insurance cover for the buildings that you are responsible for

Tenants Improvements Declared Value

Alterations or modifications made to your rented property by you at your own cost

Annual Loss of Rent Payable

Electronic Equipment & Computers (including EPOS systems and computerised tills)

Laser Machines, Laser Heads & Associated Ancillary Equipment / Spares

Business Equipment and All Other Contents

General Stock (This includes Creams, Lotions etc)

Refrigerated Drugs, Medicines or Vaccines

Non- Refrigerated Drugs, Medicines or Vaccines

Specified All Risks Cover

Cover for property away from the premises - please indicate each item and replacement value

Fixed & External Glass Cover

Standard Limit - £2,000
Other

Included at a Standard Limit of £2,000 - Please Indicate If Not Sufficient

Goods In Transit

Standard Limit - £2,000
Other

Included at a Standard Limit of £2,500 - Please Indicate If Not Sufficient

Money During Business Hours and In Transit

Standard Limit - £5,000
Other

Included at a Standard Limit of £5,000 - Please Indicate If Not Sufficient

Money in Locked Safe outside Business Hours

Standard Limit - £4,000
Other

Included at a Standard Limit of £4,000 - Please Indicate If Not Sufficient

Money Not In Locked Safe

Standard Limit - £500
Other

Included at a Standard Limit of £500 - Please Indicate If Not Sufficient

Business Interruption

Cover for financial compensation following an insured loss under the Material Damage cover. This cover is designed to help the business return to a normal trading position as quickly as possible.

Annual Gross Income

Indemnity Period

12 Months
24 Months
36 Months

You should select a period allowing for the maximum time your business will be affected if your premises were completely destroyed. There are many factors to consider, such as the time to rebuild or source a new premises and to replace machinery and lost business.

Annual Loss of Rent Receivable

Financial protection against income loss when a rental property / business area becomes uninhabitable due to an insured event (like fire or flood), forcing tenants to move out

Terrorism

Cover for damage caused to specified assets as a result of terrorist activity

Is Terrorism cover required?

Yes
No

Public Liability

Cover in respect of your legal liability to pay compensation including legal costs for: accidental death or personal injury to any person excluding employees and accidental loss or damage to third party material property.

Do you require Public Liability

Yes
No
Other

Included at a Standard Limit of £5,000,000 - Please indicate if an alternative limit is required

Annual Turnover for the next 12 months

Products Liability

Cover in respect of your legal liability to pay compensation including legal costs for: accidental death or personal injury to any person excluding employees and accidental loss or damage to third party material property arising from products that you have supplied.

Do you require Products Liability

Yes
No
Other

Do you manufacture any products (including white labelling / own branded)?

If yes, please provide details below including where you source products to white label / brand (UK, EU, USA) - Further information may be required

Employers Liability

Cover to protect your business against damages and legal costs that arise as a result of claims from employees suffering an injury or disease due to, and during their employment

Do you require Employers Liability

Yes
No

£10,000,000 Legal Required Minimum Limit of Indemnity

What is your estimated annual wageroll for the next 12 months

Personal Accident

Cover that will provide financial protection against specific employees (Principals, Partners, Proprietors & Directors Only) in respect of death or specific degrees of disablement caused solely and directly as a result of accidental bodily injury

Do you require Personal Accident Cover

Yes
No

Legal Expenses

Cover for your business to be able to pursue or defend its legal rights for specific business related disputes

Do you require Legal Expenses

Yes
No

£100,000 per claim as standard, £1,000,000 in the aggregate

Risk Information, Protection & Security

Do you have a written Health & Safety policy in place *

Yes
No

Has the Electrical Installation tested by a certified NICEIC Contractor within the last 5 years and all reported defects remedied *

Yes
No

Are the premises protected by an intruder alarm system, under your sole control *

Yes
No

What type of intruder alarm is this (BT Redcare/Dualcom/audible only etc) *

BT Redcare
Dualcom
Audible
Other

Is the intruder alarm connected to a Central Monitoring Station *

Yes
No

Is there an annual Maintenance contact for the intruder alarm with an accredited alarm maintenance company? (NACOSS, SSAIB etc) *

Yes
No

What is the Level of Police Response *

Level 1
Level 2
Level 3
Not Applicable

Is there CCTV at the premises *

Yes
No

Are accessible external doors and windows protected by grills & shutters *

Yes
No

Are the premises protected by a fire alarm *

Yes
No

Is the fire alarm triggered automatically or by manual call points, or both *

Automatically
Manual
Both
Not Applicable

Is the fire alarm connected to a Central Monitoring Station *

Yes
No
Not Applicable

Do you undertake fire risk assessments *

Yes
No

Are the premises fitted with sprinklers & are under a service contract? *

Yes
No

Are all waste bins stored externally and at least 10 metres away from the premises? *

Yes
No
Confirm in additional information section

What Frequency are the waste collections? *

Daily
Weekly
Monthly

Contruction of Premises

Standard Construction (Stone, Brick, Slate & Tile)
Non Standard (Timber, Felt, Thatch & Other)

Roof Type

Pitched
Flat Roof <50%
Flat Roof >50%

Business Premises are self contained (own entrance and not shared) *

Yes
No (Provide Additional Information)

Claims Information

Have the Proposer(s), Partner(s) or Directors(s) suffered a loss, claim or incident (which may give rise to a claim) at these premises, or any other premises, whether insured or not within the last 5 years? Is yes, give details below.

Material Facts

Have any Directors, Trustees, Officers and/or Partners been convicted or charged but not tried for a criminal offence (non motoring)

Yes
No

Have any Directors, Trustees, Officers and/or Partners been declared bankrupt or the subject of bankruptcy proceedings

Yes
No

Have any Directors, Trustees, Officers and/or Partners been involved in another company within 6 months before receivership/insolvency

Yes
No

If Yes to any question above, please provide additional information below

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