Gothic Insurance Brokers Ltd
Gothic House
Station Rd, Old Harlow
Essex CM17 0AP

Tel – 01279 429024
Fax – 01279 433383
Email –






Office Insurance Quote

Where did you hear about us?

If other please specify:

Disclosure Statement

Please ensure that all information you provide is correct and that you answer all questions accurately.

These details will form the basis of the insurance policy and any incorrect information could invalidate all or part of the insurance contract.

The proposer(s), or any partner, or director have never:-

a) been declared bankrupt or disqualified from being a company director

b) had any County Court Judgement(s) or Sheriff Court Decree(s)

c) had a company go into liquidation or become insolvent

d) been convicted or have any prosecutions pending or been given an official police caution, in respect of any criminal offence other than motoring offences

Yes No

The Business


Proposer(s) Name &/or Trading Name

Business Address
Email Address
Telephone Number
Full description of business activites
How many years has the company been trading?
Years trading at CURRENT PREMISES ?

The Premises


Are the premises:


Occupied regularly throughout the year?
Fully occupied solely by the Business with no residential accommodation, and at one location? Yes No
Free from flooding, in an area free from flooding & at least 250 metres from the nearest watercourse? Yes No
Built of brick, stone, concrete and entirely of non-combustible materials? Yes No
Have roofs built of slates, tiles, concrete, and entirely of non-combustible materials? Yes No
Not of 'listed' construction? Yes No
Free from, and in an area which is free from, any signs of subsidence, heave and/or landslip? Yes No

If you have answered 'No' to any of the questions in this section please give full details


Please tick all the security measures that are in place at the premises.

External Doors - Yale lock

External Doors- 5 Lever Deadlock

Window Locks

Window Bars or Grills

Metal Roller Shutters

C.C.T.V. (Internal)

C.C.T.V. (External)

24 Hour Security

Covered Shopping Centre- Closed at night

Alarm System

Type of alarm

Cover Required

Do you want to extend the standard cover to include:

Accidental Damage



If cover below not required - leave blank
Buildings £
Tenants Improvements £
Fixtures & Fittings £

Electronic Business Equip. (tills, computers, etc.)

General Contents £

If you ever hold stock or trade samples please give details and sum insured here

Additional Covers



Goods in Transit (own vehicles) £
Loss of Money £
Business Interruption (BI) £
Indemnity Period (BI)
Loss of Money £
Public Liability

Claims History

Please give FULL details below of any claims by you or your company within the last five years

Please give dates, circumstances & full description of any claims

Additional Information

Please add any information you feel may affect the quotation.

How would you like to be contacted?



TELEPHONE: 01279 429024
01279 429024

Authorised & Regulated by the
Financial Service Authority
Firm Number: 300031



Gothic Insurance Brokers Ltd. is registered in England. Company Reg. Number 880423. Registered Office: Gothic House, Station Rd, Old Harlow, Essex CM17 0AP

Copyright © 2011 Gothic Insurance Brokers Ltd.