Tenant Contingent Cover Scheme

Client
Proposer
Address (line 1)
Address (line 2)
Town/City)
Post Code
Telephone
Mobile
Email
Landlord
Landlord Name
Address (line 1)
Address (line 2)
Town/City)
Post Code
Telephone
Mobile
Lease Details
Lease start date
Lease period
Dates of any breaks
Dates of any breaks
Dates of any breaks
Additional notes
regarding breaks
Has any insurer cancelled your insurance or refused to renew it?
YES
NO
Have you or any of your directors, officers or business partners ever been convicted (or charged but not yet tried) of any criminal offence (other than motoring convictions)?
YES
NO
Have you or any of your directors, officers or business partners ever been declared bankrupt or insolvent or has any business which you were director or involved in management gone insolvent or into liquidation, administration, receivership or entered into arrangement with creditors?
YES
NO
Claims
Have you ever had an insurance claim in the last 5 years?
YES
NO
Risk Address
Address (line 1)
Address (line 2)
Town/City)
Post Code
Nature of Occupancy
Please select

Retail, Offices, Surgeries and salons

Licenced Premises (Excluding nightclubs)

Food retailers/restaurant

Light Industrial, engineering, manufacture, motor trade. (Excluding, recycling, scrap yards, plastics manufacture & tyre fitting/retailer)

Please specify
particular trade
Is the property standard construction? ( Brick, stone, block, walls, slate, tile metal roof with Flat felt on timber roof up to 25%?
YES
NO
Will the property be unoccupied for a continuous period of more than 30 days?
YES
NO
Level of buildings cover

Please select value of cover required