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Your details

Period of Insurance

1 & 2 Buildings and Contents Cover

Property to be Insured




Property belonging to you:


If 'No' state:

Note: If not known, or more than 10 years ago we shall need a certificate from a qualified electrician.

Note: Only permanent business activities need to be disclosed e.g. doctor's surgery, social club and similar.

Are the Buildings:

Do you require cover for damage to:

3. Loss of Revenue

Minimum sum insured provided is £10,000. Please state if higher limit required.


Note: The revenue must represent the projected Annual Revenue, i.e. money paid or payable to you as property owners for the hire or letting of buildings at the premises described above, suitably adjusted should the maximum Indemnity Period exceed 12 months.

4. Money
5, 6 & 7. Public, Employers' Liability and Libel & Slander
8. Glass and Sanitary Ware for which you are responsible

(applicable only if the Buildings are not covered)

9. Personal Accident

(see Summary of Cover for details)

10. Fidelity Guarantee
11. Loss of Licence
12. Deterioration of Freezer Stock

State in respect of each freezer or cabinet:

Description Age (years) Sum Insured (£)

(Maximum £1,000 per cabinet)

13. No Claims Discount and Application of Excess Protection

If Yes, a register of the volunteer drivers' names is to be kept by the Management Committee and it is to be available on request.

14. Legal Expenses

Is cover to include:

Claims History

Applying to all sections of cover

If Yes show details below

Year Details Paid Cost (£)
(if any)
Estimated Cost (£)
(if outstanding)

Long Term Undertaking

Note: If you agree to renew your policy for 3 years, you are eligible for a 5% discount off each section's premium, provided your total premium is at least £100.

Premium Instalments

Note: To qualify the annual premium must be at least £100. We will send you a Premium Instalment Plan for completion.

Duty to disclose Material Information

Material Information is information that would influence an Insurer in deciding whether a risk is acceptable and, if so,the premium, terms and conditions to be applied. Failure to disclose all such information or false statements could result in the policy being rendered void, so that claims would not be paid.

Before inception of cover: All Material Information must be disclosed to Insurers to enable terms to be negotiated and cover arranged. This is not limited to answering specific questions that may be asked by Aon or the Insurer. Any changes that may come to light both before and after a quotation has been given must also be notified.

After inception of cover: The duty to disclose is re-imposed when there are changes or variations in cover and when the policy is renewed or extended. In addition, changes which substantially increase the risk, or relate to compliance with a warranty or condition in the policy must be notified at once.

To ensure that cover is not prejudiced, please refer to Aon if there is any doubt as to what information needs to be disclosed.

6. Declaration

I/We declare that to the best of my/our knowledge and belief:

  1. The above statements and particulars whether written by me/us or by others are true and complete.
  2. I/We have not withheld any material fact.
  3. No Insurer has declined my/our proposal, cancelled or refused to renew my/our policy, required an increased premium, special terms or conditions for any of the insurance proposed for.
  4. Neither I/we, nor any other principalmembers of this organisation have been convicted of any criminal offence other than a motoring conviction.
  5. I am/We are not aware of any existing circumstances which have resulted or could result in a dispute which may give rise to any payment under this insurance and I/we understand that no such circumstances can be accepted as a foundation of a claim under this insurance.
  6. I/We declare that the proposer is registered in the United Kingdom, the Isle of Man or the Channel Islands.
  7. To the best of my/our knowledge no partners, principals or directors have:
    • Been subject to any county court judgements
    • Had any Insurer decline or refuse to renew Insurance or impose any special terms for acceptance
    • Been convicted/charged/cautioned in respect of any criminal offence
    • Been declared bankrupt or disqualified from being a company director or involved in any company that went into receivership or liquidation
    • Been subject to a recovery action by Customs & Excise or the Inland Revenue

A copy of this proposal should be retained for your records.

Data Protection Act

We may use the personal and business details you have given us or which are supplied by third parties, including any details of your directors, officers, partners and employees, to provide you with a quotation; deal with your policy; to search credit reference agencies who may keep a record of the search; to share with other insurance organisations to help offset risks, to help administer your policy and to handle claims and prevent fraud; to support the development of our business by including your details in customer surveys, and for market research and compliance business reviews which may be carried out by third parties acting on our behalf. You must ensure that your directors, officers, partners and employees consent to our using their details in this way or you must notify us of any objections.

We may need to collect data relating to Insured Persons, which under the Data Protection Act is defined as sensitive (such as medical history of Insured Persons) for the purpose of evaluating the risk or administering claims which may occur. By signing this form you consent to such information being processed by us. You must also ensure that you make this fact known to the Insured Persons and obtain their explicit prior consent to pass this information to us for these purposes.

We may share your details with other companies within the Allianz group of companies or pass them to third parties so that we may tell you by telephone, email or post of products and services which we think may be of interest to you. If you do not want to know about these products and services, please write to: Customer Satisfaction Manager, Allianz Insurance plc, 57 Ladymead, Guildford, Surrey, GU1 1DB to let us know. Your details will not be kept for longer than is necessary.

Under the Data Protection Act 1998 individuals are entitled to a copy of all the personal information Allianz Insurance plc holds about them. Please contact the Customer Satisfaction Manager at the address above.

Personal details may be transferred to countries outside the EEA. They will at all times be held securely and handled with the utmost care in accordance with all principles of English law.

Aon UK Limited is authorised and regulated by the Financial Conduct Authority.

Aon UK Limited, 8 Devonshire Square, London EC2M 4PL. Registered in London number 210725 | Published by Aon UK Limited. © Copyright Aon UK Limited 2012. All rights reserved.