BIBA

Butterworth Spengler
Commercial Ltd

Butterworth Spengler
Facilities Ltd

Butterworth Spengler Professional Risks Ltd

Authorised and regulated by the Financial Conduct Authority

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Quotation Form

Complete the form below and we'll calculate your quote and contact you directly to go through the details.

Date Cover Required

If we have asked you to quote a reference, please enter it here
Are you an ActSmart member?	Silver Gold Platinum No
If you are please provide your member No.

Have you or your mechanics achieved Cytech Technical Two or above accreditation?	Yes No
Current Insurer
Current Renewal Premium £

Sums Insured
A. BUILDINGS
Building	£	Rebuilding Figure Including a value for Architects fees, removal of debris.
Tenants Improvements	£

B. CONTENTS
1. STOCK
Cycles & Accessories (incl. customers cycles in for repair etc) and any other stock for sale.	£	Original Trade Price Including removal of debris.

2. ALL OTHER CONTENTS
Equipment and other contents including computers, tools, tills telephone system etc.	£	Replacement Figure Including removal of debris.

Employers Liability Tracing Office
Claims made against Employers liability insurance can involve instances of long term injury and disease occurring over many years and to assist in your protection Insurers are required to obtain certain information from all employers to assist in tracing the insurers involved. Can you therefore answer the following questions:
1. Do you have any employees?	Yes No
If Yes, please advise your Employer reference number - ERN (see note below).
The ERN is often referred to on tax forms as employer’s PAYE reference and is provided by HMRC to every business registered with them as an employer. It can be found on many official documents such as P11D, P45 and P60. For example it is in the format 765/PA12345 (not the 13 digit number).
ERN
Some employers who pay all their employees below the PAYE threshold (£503.00 monthly) will be exempt as they do not have an ERN. If this applies to you, please indicate below.
2. We do not have an ERN as all our employees are paid below the PAYE Threshold (see note).	Yes No

Additional Cover
1. Money in Transit (£2500)	£	If you require more than standard Policy limits as shown within the Policy Cover.
Money at Premises (business hours) (£5000)	£
Money in Safe (non business hours) (£5000)	£

Trading
Do you supply goods to the USA/Canada?	Yes No
Do you import goods from outside the EU?	Yes No
Do you sell second-hand bicycles?	Yes No
If Yes does this activity exceed 25% of sales?	Yes No
Number of years in business at these premises?
Have you had any insurance claims in the past 5 years?	Yes No
If yes, please specify breif details of date, type of claim and payment:

Internet sales
Does your website allow purchases to be made?	Yes No
If yes, please advise approximate percentage of sales derived from the Internet.	%

Sale of hazardous goods
Do you store or sell any of the following types of goods?	Yes No
Medical or health products. Flammable liquids or gaseous fuels including "camping gas" type canisters fireworks. Children's toys which do not carry the CE mark as per the criteria set by the EC Toy Safety Directive (88/378/EEC).
If yes, please supply full details

Important information
Construction of walls and roof of premises and any out-buildings
Walls
Roofs
Out-Buildings
Is there any sign of cracking, subsidence or heave in your property or in neighbouring properties, or is the area a recognised subsidence area?	Yes No

Are the premises alarmed?	Yes No
If Yes please provide details of the type of installation, ie. method of signalling such as BT Redcare/DualComm and the level of police response.
NACOSS or SSAIB approved?	Yes No
Annually Maintained under agreement?	Yes No

Please detail physical protections e.g. security shutters to Doors and Windows
Doors
Windows

Additional Information
Do you attend exhibitions?	Yes No
If so, please give an approximate number
Are there any other activities you engage in other than retail including repair and/or hire of cycles?	Yes No
If so, please give full details

I confirm I have read the Statement of Fact and comply with the statements made.	Yes
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