Lloyd Manley Associates - Clubs and Pubs

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Please complete the following Club Enquiry form

General:
Club Name:
Address 1:
Address 2:
Post Code:
Telephone:
E-mail:
Business description:
Type of Firm:
	Limited Company
	Registered Charity
	Other
If 'Other' please specify:
When established:
Annual Turnover:	£
Have you had any claims in the last 5 years:	Yes No
If Yes, please give details:
Premises:
Are premises occupied only by you?	Yes No
Do you have Sports Grounds or Facilities?	Yes No
If Yes, please give details:
Are your premises detached?	Yes No
Non combustible construction?	Yes No
	Combustible roof % Combustible Linings %
Are fire extinguishers regularly serviced?	Yes No
Do you have a fire alarm?	Yes No
Do you have an intruder alarm?	Yes No
Type of signalling -	Redcare Other Monitored Dialler Bells only
Do you have portable heaters	In office areas only Yes No
	Elsewhere Yes No
Is your electrical system regularly checked?	Yes No
Do your premises have an IEE Certificate?	Yes No
Sums Insured:
Buildings	£
Stock of High Risk Items (Cigarettes, tobacco, wines, spirits)	£
Other Stock	£
Computers & Electrical Office Equipment	£
Other Business Equipment	£
12 Months Gross Profit	£
Do you require a longer indemnity period?
Loss of licence indemnity	£
Annual amount of cash in transit	£
Maximum amount on premises or in transit	£
Maximum amount in safe	£
Maximum amount in gaming machines	£
Number of gaming machines operated by you
Public Liability limit of indemnity required
Activities:
Number of employees
Annual wage roll	£
Number of officials
Total number of members
Number of active members
Do you have a written Health and Safety Policy?	Yes No
Do you require Fidelity Guarantee Cover?	Yes No
Limit of indemnity for:-
Steward	£
Secretary	£
Treasurer	£
Do you require Personal Accident cover?	Yes No
Amount of weekly benefit for:-
Officials	£
Staff	£
Members	£
(Leave section blank if part cover required)
Your name:	Position:

Authorised and Regulated by the Financial Services Authority for General Insurance Business No. 302600