Name of Company / 
Business                    

Address of Office / 
Surgery to be insured

Post Code                     

Nature of business      Sole Trader Partnership Limited Company Other      

Trade or Occupation 

PLEASE LEAVE BLANK ANY SECTIONS YOU DO NOT WANT TO COVER.

Section 1 Buildings
Full Rebuilding Cost             
Loss of Rent (12 months)      

Section 2 Contents
Contents of office or surgery excluding items detailed below
Computers and other electronic office equipment                 
Drugs and Medicines                                                              
Tenants improvements (if you don't own the building)           
Portable Equipment                                                                
Refrigerator Contents                                                              

Section 3 Business Interruption
The profit you would lose if unable to trade for 12 months     

Do you require cover for increased costs of working              
following a claim?  If so, how much do you estimate you
will need?

Section 4 Computer Breakdown 
Total value of computer equipment at your premises            

Do you require cover for the increased costs of working       
following the breakdown of computer equipment? (This
includes the reinstatement of data) If so, how much do you        
estimate you will need?

Sections 5 & 6 Employer's / Public / Products Liability
Employer's Liability £10,000,000         
Public / Products Liability £2,000,000 

General Information

Are your premises built of brick, stone or concrete and roofed with slates tiles or concrete?   Yes No

Has your business been involved in any incidents in the last 5 years which did or could have given rise to a claim of a type which this insurance is intended to cover?           Yes No

Date from which you need cover to start (dd/mm/yyyy)    

Please enter below any further information that you think we should know  before preparing your quotation.

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Copyright ©  [Harvington Services Ltd]. All rights reserved.
Revised: January 09, 2007 .