Insurance and Financial Services
for the Chiropractic Profession

To discover the benefits of insuring your property through Lloyd & Whyte simply complete the brief details below and we will contact you with a quotation.

You

Salutation *	Please Select Mr Mrs Ms Miss Dr
Forename *
Surname *
Date of birth *
Address *
Postcode *
BCA Member *	Please Select Yes No
Telephone *
Email Address
Mobile
What prompted you to visit our website? *	Please select BCA Conference Contact Magazine In Touch Insert Mailshot PR Activities Word of mouth

The Property

Risk Address
Risk Postcode
Are you the sole owner? *	Please select Yes No
If no, please provide details of other owners
Other owner 1
Name
Date of birth
Relationship to proposer
Occupation
Other owner 2
Name
Date of birth
Relationship to proposer
Occupation

How long has the property been owned? *	months/years
What is the use of the property? *	Please Select Residential Commercial
Will the property be unoccupied at any stage? *	Please Select Yes No
If yes, for approximately how long will the property be unoccupied? *	weeks/months
If yes, why is the property unoccupied? *	Please Select Renovation Demolition For Sale Awaiting Tenants

Type of Property *	Please select Detached Semi Detached Terraced Bungalow Flat Other
Year of Construction
If a house, number of bedrooms?	Please select 1 2 3 4 5 6 6+
Wall construction material *	Please select Brick Stone Timber Metal Frame Metal Clad Cobb Glass
Roof construction material *	Please select Tile Slate Wood Thatch Glass Metal Clad
Is there any flat roof areas on the property? *	Please select Yes No
If yes, what percentage of the roof is flat?	%
If yes, what material is used on the flat roof?	%
Floor construction material? *	Please select Brick Stone Concrete Timber
Stairs construction material? *	Please select Brick Stone Concrete Timber
Is the property subject to any preservation orders? *	Please select Yes No
If yes, which? *	Please select Grade 1 listed Grade 2 listed Conservation Area
Is the property free from heave, landslide and subsidence? *	Please select Yes No
Is the property free from flooding? *	Please select Yes No

Have you or any partner or Director ever:

Been declared bankrupt, insolvent or disqualified from being a company director?	Please select Yes No
Been convicted or charged or given an official police caution in respect of any criminal offence, other than a motoring conviction?	Please select Yes No
Had any county court judgements or sheriff court decrees in the last 5 years?	Please select Yes No
Had any insurance proposal declined, renewal refused, special or increased terms or had insurance cancelled mid term?	Please select Yes No

Security & Occupancy

Do all external doors (and internal doors if premises is not solely occupied by you) have 5 lever mortice deadlocks? *	Please select Yes No
Do all accessible windows, fanlights and skylights have key operated locks? *	Please select Yes No
Is the property protected by an intruder alarm system *	Please select Yes No
Do you accept refferals from the DSS or Students? *	Please select Yes No

Cover Details

Rebuilding value of the property *
Contents sum insured *
Landlord's contents *
Contents in communal areas *
Loss of rent receivable *
Period	Please select 12 months 24 months 36 months
Public / Property Owners Liability limit	Please select £1m £2m £5m
Employers Liability cover required	Please select Yes No
Cover required	Please select Standard Accidental Damage
Additional cover required	Subsidence Terrorism

Claims

Have you suffered any claims in the last 5 years *	Please select Yes No
If yes, please give details of dates, incident and costs

General Information

Existing Insurer *
Renewal Date *
Current Premium *

*Denotes compulsory field

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