Name
Postcode
E-mail Address*
Contact Telephone Number*
Unique Reference Number
Do you wish your quotation to include cover for ‘acts of terrorism’?	Yes     No
Have you suffered any loss in the last 5 years (whether insured or not) in respect of any of the insurance now being applied for?	Yes     No
If Yes, please provide details, including amounts involved:
Your Sums Insured - please enter a sum insured against each £ shown below. Where cover is not required for the item described, please enter a zero.
Contents at your premises
Description	Sum insured
Computer and ancillary equipment £
Other electronic office equipment £
Business documents and records £
Tenants improvements £
All other office contents £
Business Interruption
Enter a Sum Insured against either Loss of Income of Increased Cost of Working.
	Sum insured
Loss of income £
or
Increased cost of working £
Optional Extensions - complete the following ONLY if cover is required.
Buildings
Sum insured £
Do you wish your quotation to include subsidence, ground heave or landslip?	Yes     No
All Risks on Specified Items away from your Premises
Enter sum insured required against each description, or a zero if not applicable. Please then tick appropriate box to indicate what territorial limit is to apply.
Description	Sum insured	UK	Worldwide
Mobile phones £
Laptop computers £
Other property £