Property Owners Risk Questionnaire 2024

If more than one property is to be insured please complete sections 1 and 2, submit the form to us and we will contact you to discuss in more detail.

Section 1: Contact details

Full Name:

Email

Phone

Section 2: Policyholder information

Is the Policyholder a:

Private individual

Company

Partnership

Date of Birth

(if you are a private individual)

Policyholder’s name:

Please note that unless there is a separate legal agreement in place this must be the name of the Freeholder. Leaseholders and other interested parties may be added later.

Correspondence address:

Address Line 1 Address Line 2 City County Postcode

(this is the registered address of the freeholder)

Has any proposer, including any directors or officers of the business, either personally or in any business ever:

Charged with or convicted of any Criminal offences excluding motoring offences and offences that are spent?

Yes

No

Had a county Court Judgement or Scottish Equivalent Awarded against them?

Yes

No

In the last 5 years been declared bankrupt or been the subject of bankruptcy proceedings, an administrative receivership, a company or partnership or individual voluntary arrangement, a Debt Relief Order, an Administration Order, a Compulsory Liquidation, a Creditors’ Voluntary Liquidation, a Winding Up Order or any equivalents in Scotland or North Ireland?

Yes

No

In the last 5 years had a policy voided, had a renewal declined, had special terms imposed by an insurer or insurance cancelled where a cancellation clause has been invoked?

Yes

No

In the last 5 years sustained any loss or had any claims made against them, whether insured or not, or are they aware of incidents that might result in a loss or claim or that are relevant to any cover available with this class of business?

Yes

No

If you have answered Yes to any of the questions above please give details:

Where applicable, does the proposer comply with the requirements of the Regulatory Reform (Fire Safety) Order 2005, or the equivalent legislation in Scotland and Northern Ireland?

Yes

No

Additional information

Is there any additional information you need to submit to the insurers regarding any policyholders or the risk?

Yes

No

If Yes please provide details:

Do you have any additional documentation to submit for this property?

Yes

No

This could include any existing policy documentation, renewal invitations, valuation reports, survey reports.

If Yes please provide details:

Please upload copies or send copies by email or post.

Max. file size: 80 MB.

Any additional information:

Declaration

Is all the information you have provided in this form an accurate and fair presentation of the risk?

Yes

No

Have you ever been convicted of any offences involving fraud, theft, false accounting or other dishonesty or an offence (whether or not in the United Kingdom) relating to companies, building societies industrial and provident societies, credit unions, friendly societies, insurance banking or other financial services, insolvency consumer credit or consumer protections, money laundering, market manipulations or insider dealing? (required)	YesNo
Are you the subject of any current criminal proceedings? (required)	YesNo
Have you any convictions for any offences other than those listed in question 1 a) above which are not spent, whether or not in the United Kingdom (excluding traffic offences unless these resulted in a ban from driving or involved driving without insurance)? (required)	YesNo
Are you or have you ever been the subject of any civil proceedings, arbitration or litigation, including proceedings that resulted in a County Court Judgment (CCJ) or other judgement debts, in the United Kingdom or elsewhere? (required)	YesNo
Are you aware of any intention to begin such proceedings against you in the future? (required)	YesNo
Do you have any judgement debts (including CCJs) made under a court order still outstanding, whether in full or in part? (required)	YesNo
Have you ever failed to satisfy any such judgement debts within one year of making of the order (required)	YesNo
Are you or have you ever been, the subject of any bankruptcy proceedings, or proceedings for the sequestration of your estate? (required)	YesNo
Have you ever entered into a deed of 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? (required)	YesNo
Have you ever been found guilty of conducting any unauthorised regulated activities or been investigated for possible conduct of unauthorised regulated activities? (required)	YesNo
Are you, or have you ever been, the subject of an investigation into allegations of misconduct or malpractice in connection with any business activity? (required)	YesNo
Have you ever, either in the United Kingdom, or elsewhere been - (required)
- refused entry to, or been dismissed or requested to resign from, any profession, vocation, office or employment, or from any fiduciary office or position of trust, whether or not remunerated? (required)	YesNo
- 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? (required)	YesNo
- disqualified by a court from acting as a director of a company or from acting in a management capacity of conducting the affairs of any company, partnership or unincorporated association? (required)	YesNo
- the subject of a disqualification direction under section 59 of the Financial Services Act 1986 of a prohibition order, under section 56 of the Financial Services and Markets Act 2000, or received a warning notice to make such a direction or order? (required)	YesNo
Have you ever been a controller, director, senior manager, partner or company secretary of a company, partnership, or unincorporated association? If you answered "no" to question 8 you may proceed to section 12. Please tick (required)	YesNo

In respect of activities regulated by the FCA have you, or any company, partnership or unincorporated association of which you are or have been a controller, director, senior manager, partner or company secretary, during your association with that entity and for a period of three years after you ceased to be associated with it, ever - (required)
- been refused, had revoked, restricted or terminated any licence, authorisation, registration, notification, membership or other permission granted by any such body? (required)	YesNo
- been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of any other disciplinary or intervention action by any such body? (required)	YesNo
- resigned whilst under investigation by, or been required to resign from, any such body? (required)	YesNo
- been the subject of any civil action which has resulted in a finding against you or it by a court? (required)	YesNo
Has any company, partnership or unincorporated association for which you have been a controller, director, senior manager, partner or company secretary, in the United Kingdom or elsewhere, at any time during your involvement or within one year of such an involvement – (required)
- been put into liquidation, wound up, ceased trading, had a receiver or administrator appointed or entered into any voluntary arrangement with its creditors? (required)	YesNo
- been declared by a court liable for any fraud, misfeasance, wrongful trading or other misconduct? (required)	YesNo
- been investigated or been involved in an investigation by an inspector appointed under companies or any other legislation, or required to produce documents to the Secretary of State, or any other authority, under any such legislation? (required)	YesNo
- been convicted of any criminal offence, censured, disciplined or publicly criticised, by any inquiry, by the Takeover Panel of any other governmental or statutory authority or any other regulatory body (other than as already indicated under 10 b))? (required)	YesNo
Are you currently a director of any company other than one which is a part of this company? (If “yes” please give details on the supplementary sheet). (required)	YesNo