Welcome to Waveney Insurance Brokers

Surgery Insurance

Complete the short form below to get a quotation or call 01473 269443

Existing Insurer Details
Renewal Date:		DD/MM/YY
Renewal Premium (£):
Insurer/Broker:
Customer Details
Proposer's Name
Address
Street
Town/ County
Postcode
Telephone Number
Email address
Property Details
Construction
Is Property Listed		Select Yes No   if yes grade 1 or 2 Select Grade 1 Grade 2
Does the Property Have a Flat Roof		Select Yes No If yes what percentage
Other Occupants
Sums Insured
Contents (Excluding Computers) £				Computer Hardware £
Buildings £				Computer Software £
Book debts £				Tenants Improvements £
Annual Gross Fee Income of the Practice £
Claims Experience
How long has the proposer been in business yrs				Any claims in last 5 years?			yes
							no
If yes, please provide following details:
Type of Claim				Payment made £			Date
Security
Do you have window locks on all accessible windows?		yes  no
Do you have 5 lever mortice deadlocks on all entrance and final exit doors at the premises?		yes  no
Is there an alarm at the premises?		yes  no
Name of Alarm Co
Is it maintained under an annual contract?		yes  no
What is the signal method?
Are the premises protected by local authority CCTV?		yes  no
Subsidence Details
Is the Property in a Flood, Subsidence, Heave or Landslide Area?		yes  no
If YES, please give details
Optional Covers
Practice Overheads	Professional Indemnity for Nurses	Inspection			Terrorism