Business Combined Insurance

Client Code*

Name of person completing questionnaire*

Insured Name*

1. Are there any changes in your business activities / operations?*

Yes
No

If YES, please advise full details

2. Have there been any material changes to fire and theft protection alarms, devices and the like during the past 12 months?*

Yes
No

(e.g. disconnection or dismantling or installation of any services)

If YES, please advise full details

3. Is there any history of flood damage at the insured location(s)?*

Yes
No

If YES, please advise full details

4. Attached to your email is a summary of your existing cover for review. Please advise if changes are required.*

Yes
No

If 'YES', please advise changes below

5. Declared Replacement Values : please update the values shown in the Schedule of Insurance

Other Insurances

Are there any other insurance needs e.g. Insurance of Income, Home, Contents, Motor Vehicle, Caravan, Boat etc, with which we can assist?*

Yes
No

Claims

1. Details of any claims that have occurred, but have not yet been reported*

2. After specific inquiry, details of any facts, circumstances or incidents (other than those already disclosed, notified to your insurer) which could give rise to a future claim.*

Information we have provided to Sarina Insurance Brokers, is to the best of our knowledge correct.

Name

This field is for validation purposes and should be left unchanged.

Other Insurances

Claims

Sarina Insurance

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