FirstUnited Insurance Brokers Ltd

Business Insurance

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Business Insurance Quotation Form

*indicates Required Fields

Full Name*

Email Address

Years Trading*

Business Address*

Description of Trade / Business*


	Have you made a claim or suffered loss or damage at your business premises within the last 3 years?*		Yes No


	Have you ever had any insurance policy cancelled or refused or have been asked to pay an increased premium?*		Yes No


	Have you ever been convicted of any offence involving dishonesty, fraud, violence, criminal damage, arson, drugs or have such a prosecution pending?*		Yes No


	Do you undertake work away from the prmises you operate from apart from delivery of goods?*		Yes No


	Does any other business occupy or operate from your premises?*		Yes No

If the answer is yes to any of the above questions, please provide full details:

Security


	Are all the premises you operate from occupied during normal business hours?*		Yes No


	Does each premises you operate from have its own seperate lockable entrance?*		Yes No


	Are all door and window openings on the ground floor of each premises secured by solid wooden apertures or grille or metal shutters?*		Yes No


	Do you a have a burglar alarm installed at the premises you operate from?*		Yes No


	Do you have a CCTV system installed at your premises?*		Yes No


	Do you have fire extinguishers installed at the premises which are regularly serviced and maintained?*		Yes No


	Do you have a safe installed at your premises?*		Yes No

Cover on Property

Would you like to insure your buildings?*

Yes No

If Yes, please input Sum Insured:
€

Would you like to insure your furniture and fittings?*

Yes No

If Yes, please input Sum Insured:
€

Would you like to insure your computers and business equipment?*

Yes No

If Yes, please input Sum Insured:
€

Would you like to insure your stocks?*

Yes No

If Yes, please input Sum Insured:
€

Would you like to insure your pland and machinery?*

Yes No

If Yes, please input Sum Insured:
€

Business Interruption


	Would you like to insure a possible interruption to your business?*		Yes No

What is your estimated annual gross revenue?

Liability Insurance


	Would you like to insure your liability towards third parties?*		Yes No

What is your annual turnover?


	Would you like to insure your liability towards your employees?*		Yes No

How many employees do you employ?

How much do your annual wages amount to?

Additional Cover

Cover for accidental damage to Buildings & Contents*

Yes No

If Yes, please input Sum Insured:
€

Cover for accidental damage on Glass, Mirrors, Signs and Sanitary ware*

Yes No

If Yes, please input Sum Insured:
€

Cover on Portable Business or Computer Equipment*

Yes No

If Yes, please input Sum Insured:
€

Theft of cash from the premises or whilst in transit*

Yes No

If Yes, please input Sum Insured:
€

Cover for Stock whilst in Transit*

Yes No

If Yes, please input Sum Insured:
€

Contact Details

These details will be only used by our Sales Representatives to contact you regarding this quotation.

Contact Number*

Preferred Calling Time

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