Risk Submission

1a: Your/Company Details

Agency Code ◊

This is a 3 or 7 digit reference and can be found on your Terms of Business Agreement with us. If you do not have an existing Agency with Keelan Westall please contact us or register for an agency reference before proceeding.

Company Name ◊

Contact Name ◊

Telephone No. ◊

Email Address ◊

Account Handler ◊

Please Select Amy Flintham Gemma Wall Lisa Smith Michelle Richards Paul Manners Rachel Elliot Sarah Beirne Sophie Roitt Val Drury KEY Unknown

1b: Insured Details

Insured Name ◊

Please enter the full legal title of the Proposer.

1c: Additional Cover

Terrorism Quote Required? ◊

Yes No

Terrorism cover is not automatically provided under any Buildings Policy however a Terrorism quotation can be provided upon request.

2a: Property Details

Postcode Lookup

Select an address, or enter manually

Risk Address ◊

 

Town ◊

County ◊

Postcode ◊

Current/Intended Occupation ◊

Name of Tenant

Age of Property

The year the building was erected, e.g. 1975

No. of Storeys

Is the property listed?

Yes No

What grade is it listed under?

Grade I Grade II

2b: Construction

Construction of Walls ◊

Brick Stone Other

Details ◊

Construction of Roof ◊

Slate Tile Concrete Other

Details ◊

Construction of Floor ◊

Wood Concrete Other

Details ◊

Is any portion of the roof flat? ◊

Yes No

What percentage is flat?

0% 50% or less Greater than 50%

What is the construction of the flat roof?

(max 200 chars)

Are there any adjoining properties?

Yes No

Is there a complete firebreak wall between them and the insured premises?

Yes No

2c: Sums Insured

Buildings Declared Value ◊

£

"Declared Value" means the Insured's assessment of the cost of reinstatement of the property insured at the level of costs applying at the inception of the period of insurance, providing due allowance for professional fees, debris removal costs and the additional cost of reinstatement to comply with European and Public Authority requirements.

Rent Sum Insured (per annum) ◊

£

The money paid or payable to the insured for tenancies and other charges and for services rendered in the course of the business at the Premises.

Sums Insured:- If Loss of Rent Cover is not required, please enter 0

Indemnity Period ◊

12 months 24 months 36 months

Maximum estimated period that income is likely to be affected following a loss.

Contents (communal) Sum Insured ◊

£

Landlords Contents in communal areas only. If any other cover is required please contact your Account Manager.

Property Owners Liability ◊

£

Employers Liability Cover required? ◊

Yes No

Wage Roll

£

Number of Staff

Nature of Staff

2d: Claims Experience

Have there been any claims settled or submitted or any incidents that could give rise to a claim in the last five years? ◊

Yes No

If you have more than 3 claims please contact your Account Handler

Date of Loss

(dd/mm/yyyy)

Amount Paid

£

Amount Outstanding

£

Type of claim

(max 200 chars)

What action was taken to avoid recurrence?

(max 200 chars)

Date of Loss

(dd/mm/yyyy)

Amount Paid

£

Amount Outstanding

£

Type of claim

(max 200 chars)

What action was taken to avoid recurrence?

(max 200 chars)

Date of Loss

(dd/mm/yyyy)

Amount Paid

£

Amount Outstanding

£

Type of claim

(max 200 chars)

What action was taken to avoid recurrence?

(max 200 chars)

Add a second claim

2e: Vacant Property Details

Is the property vacant/part vacant? ◊

Yes No

A property is classed as vacant if not furnished adequately for use and/or left for 30 consecutive days or more.

Why is the property vacant?

In between Tenants Refurbishment Damaged Other

Please state the previous occupation (tenant/trade) and, if known, proposed new occupation

Please provide a details list of proposed works, including any structural works and planning permission (granted or not)

Please provide details of damage, including whether a claim has arisen

Please provide details

How long has the property been unoccupied?

How long is it estimated it will remain vacant?

What security is in place?

(max 200 chars)

What percentage of the property is vacant?

0% 1% to 25% 26% to 50% 51%+

2f: Multiple properties

 If you need to save this and add a further property, click here.

3a: Other Information

Holding Broker?

Yes No

Current Insurer

Any other insurer/broker approached for a quotation?

Yes No

Details

Renewal Date

(dd/mm/yyyy)

Target Premium

£

Deadline Date

(dd/mm/yyyy)

3b: Additional Information

Any other relevant details

3c: Promotional Code

 Promotional code