Please complete the details below as fully as possible.

Proposer Details

Full Name: Corresponence Address: Postcode: Telephone: E-mail Address:

Risk Address: (if different) Postcode: Telephone:

Full description of your business and type of goods carried:

Full description of your premises e.g.shop, public house, factory, warehouse, etc:

Do you have a claims history (within 5 years) Yes No If you ticked yes, you must fill in the section below
Date	Details of loss	Amount