Wholesale Broker Form – A10 Insurance Brokers

Contact Form Demo

Broker Name

Broker Contact Name

Contact Phone Number

Email Address

Deadline

Renewal Date

Holding Insurer

Target Premium

Proposer's details

Company Name

Trading Name

Contact Name

Contact Number

Co. Registration Number

Contact Email Address

Date of Birth

Business Description

Date Company Established

Number of Employees

Current Turnover

Turnover split by department as a percentage

Sales %

Service %

MOT %

Repair %

Spraying %

Does the proposer specialise in customising, modification or other major alteration works to vehicles?

Yes

If yes, provide details:

Business speciality - State percentage split below.

Motor cars %

Sports or high performance cars %

Veteran / vintage or classic cars

Light goods vehicles %

Heavy goods vehicles %

Motorcycles %

Buses, coaches and other vehicles designed to carry over 8 people.

Agricultural vehicles & mobile plant

Other %

Yes

Please specify

Claims occurring in the last 5 years - MOTOR

List any claims occurring in the last 5 years - MOTOR

Load any supporting documentation

Choose File

Claims occurring in the last 5 years - NON MOTOR

List any claims occurring in the last 5 years - NON MOTOR

Load any supporting documentation

Choose File

Risk Information

Are the premises solely occupied by the insured?

Yes

Have the premises been previously affected by flood?

Yes

Are the premises at risk of flooding or situated within 250 metres of a watercourse, canal, lake, reservoir or dam?

Yes

Are the water pipes protected against freezing?

Yes

Is there a H&S policy in force and up to date

Yes

Is the property built on made up ground?

Yes

Is the property heated by low pressure hot water or steam, fixed oil fire space heaters fee from a fuel tank in the open, overhead gas or electrical appliances?

Yes

State type of fixed heating

Any portable heaters? Give details.

Has the Electrical system been inspected in the last 3 years and been certified IEE (or equivalent) compliant and is a test certificate available

Yes

Has the property or and adjacent property previously suffered from any subsidence, heave or landslip?

Yes

Are any trees (in excess of 10m in height) within 10 metres of the property?

Yes

Does the building have any visible signs of cracks?

Yes

Construction

State age of property

State number of years at this address

State number of years trading elsewhere

State number of storeys

Describe the materials used for walls, floors, roof, staircases and internal partitions, etc. Also, detail the type and extent of any composite (sandwich) panels used; their location in the building and the type of core material (PIR, PUR, etc.) including age and condition. Please provide FULL details.

Fire Protection

Is welding undertaken?

Yes

Please state percentage of turnover

Are FEA’s installed and regularly maintained?

Yes

Is there any spraying?

Yes

Is there a proprietary built spray booth with extraction?

Security

Name of alarm company?

Alarm signalling type - Redcare, Digicom, Bells etc.

Do you have police level 1 response?

Yes

Are PHT boxes secured to fabric of the building or vehicle lifting platforms

Fabric of the building

Vehicle lifting platforms

Both

Other

Type of vehicle access to the site including gates / barriers, etc.

Perimeter security including type height of walls, fences and gates

Details of any other physical protections (CCTV, shutters, access control, window bars)

Vehicle Key Security – During working hours

Vehicle Key Security - Overnight

Material Damage

Subsidence

Yes

Terrorism

Yes

Buildings (Declared Value)

Tenants Improvements

Rent Payable

Machinery, Plant, F & F

Computer & Ancillary Equipment

Portable Hand Tools, incl. hand held diagnostics

Stock (ex vehicles)

Insured’s Vehicles

Customers Vehicles

Attractive Stock

Fixed Diagnostics Machinery

Miscellaneous Items

Excess Required

What is the percentrage split of the sum insured of vehicles?

In a locked building

In a locked and enclosed compound

In the open e.g. Forecourts

Elsewhere in the open

What security precautions are used to protect vehicles in the compound/open?

Security posts/hoops

Dwarf walls

Security guards

Wheel clamps

Palisade Fencing

Business Interruption

Gross Profit sum insured

Indemnity period 24 Months (minimum)

Loss of Rent receivable

Increased Cost of Working sum insured

Book debts sum insured

MOT Loss of Licence required?

MOT fee income £

Money

Sums insured.

Non-Negotiable(s)

In transit in the custody of a security company

Or in transit by insured or employee

On premises outside business hours

On premises during business hours

Contained in a locked safe

Or in transit by insured or employee

Details about Safe:

Make

Model

Description

How secured?

Annual cash carryings

Indicate the limit of indemnity required?

By security company?

P.A. Assault : Capital sums

£5,000

£10,000

£15,000

P.A. Assault : Weekly benefit

£50

£100

£150

Wrongful Conversion

Own carrying?

Stock in trade (vehicle components, parts, accessories etc.)

Goods in Transit - Sums Insured

State the estimated turnover during the next 12 months for sales of all vehicles

Motor vehicles carried on a vehicle and /or trailer designed for the purpose

Maximum number of vehicles regularly used for transporting stock / equipment

Maximum number of vehicles regularly used for transporting vehicles

Public & Employers Liability

Public Liabiliaty Amount

£2,000,000.00

£5,000,000.00

Please state the number of employees in the following areas of your business

Principals and Partners - administration and sales

Principals and Partners – Manual

Employees – Clerical and Sales

Employees – Pump attendants and cashiers

Employees – Mechanics/Fitters/Technicians

All others (please specify)

Road Risks - List of Own Vehicles

Provide an up to date MID list or fill out the boxes below.

Choose File

Make / Model

Engine size

Registration

Year

Value £

Make / Model

Engine size

Registration

Year

Value £

Make / Model

Engine size

Registration

Year

Value £

Make / Model

Engine size

Registration

Year

Value £

Make / Model

Engine size

Registration

Year

Value £

Drivers

Name

Date of Birth

Occupation

SD & P

Business Use

Name

Date of Birth

Occupation

SD & P

Business Use

Name

Date of Birth

Occupation

SD & P

Business Use

Name

Date of Birth

Occupation

SD & P

Business Use

Name

Date of Birth

Occupation

SD & P

Business Use

Will any of the vehicles be driven by a person who:

Has any DVLA aware medical conditions

Has any convictions

State which extensions are required

Windscreen (Comprehensive only)

Accompanied demonstration

Loan and Hire cover

Unaccompanied Demonstration

Unnamed relatives/friends

State maximum value on any one vehicle:

State number of Trade Plates held:

Excess Required

No Claims Discount applicable

Has an Insurer ever:

Declined, cancelled or refused to renew a policy for which you are proposing

Yes

Been disqualified by a court from acting as a director of a company or from acting in a management capacity or conducting the affairs of any company, partnership or unincorporated association?

Yes

Been involved with any company which went into receivership or administration?

Yes

Been refused, restricted in, or had suspended, the right to carry on any trade, business or profession for which specific licence, authorisation, registration, membership or other permission is required?

Yes

Have you the Proposer or any Partner or any Director, whether in the United Kingdom or elsewhere ever:

Yes

Been the subject of any civil proceedings, arbitration or litigation, including proceedings that have led to or may lead to a County Court Judgement (CCJ) or other judgement debts

Yes

Been the subject of any bankruptcy proceedings?

Yes

Entered into a deed or arrangement or an individual voluntary arrangement (or in Scotland a trust deed) or other agreement in favour of your creditors, or are you doing so?

Yes

Risk Management Features

Driving Restrictions – applied by insured

Yes

Driving licenses checked annually

Yes

Any Dashcams on own vehicles

Yes

Regular Vehicle Checks

Yes

Employee driving incentives

Yes

Designated Parking bays

Yes

Vehicle parking away from Business premises overnight (security measures applied)

Yes

H & S Policy

Yes

Accident Book

Yes

First Aider

Yes

Employee Training Records in place

Yes

Risk Assessments Carried

Yes

Waste Collection

Yes

PAT Tested & Recorded

Yes

Plant Maintenance programme

Yes

Portable Heaters used

Yes

Combustible waste within 5 metres of building (or kept in metal lidded bin).

Yes

Bunded Fuel tanks

Yes

Body repairers only – water based paints only

Yes

Vehicle sales only – code of practice for demonstration vehicles – retain key etc.

Yes

Additional information

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