Who recommended you to us?
Occupied By (i.e. commercial tenant or professional let, DSS etc.)
Have you or any of your partners or directors either personally or in connection with any business in which you have been involved (please give details)
a) previously held insurance for any of the covers to which this Proposal relates at these premises or elsewhere? ---YesNo
If ‘Yes’ please advise name of Insurers and policy number
b) held any insurances (in respect of the covers to which this Proposal relates) which have subsequently been
i) declined? ---YesNo
ii) terminated? ---YesNo
iii) refused renewal? ---YesNo
iv) subject to special terms? ---YesNo
c) ever been convicted or charged (but not yet tried) with a criminal offence other than a motoring offence? ---YesNo
d) ever been declared bankrupt or are the subject of any current bankruptcy proceedings or any voluntary or mandatory insolvency or winding up procedures? ---YesNo
e) ever been the subject of a recovery action by Customs and Excise or the Inland Revenue? ---YesNo
f) Are there any other material facts you should disclose? ---YesNo
I/We declare that to the best of my/our knowledge and belief all the statements and particulars made are true in every respect.
I/We understand that any material fact, which is information that may influence the Company in the acceptance and terms provided, has been disclosed and recorded.