Golf Club Quote Request Please provide as much information as you can to assist us in providing your quotation quickly. Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Web Site General Questions Broker: Contact Name: Email: Telephone: Name of Insured: Legal Trading Status: Business Description: Year Established: Client Contact Surname: Client Contact Forename: Risk Address 1: Risk Address 2: Risk Address 3: Risk Address 4: Postcode: Tel: Email Website: Policy Renewal Date: Existing Insurers: Target Premium: Holding Broker: Quote Deadline: Claims Have there been any losses or incidents giving rise to a claim during the last 3 years? PAYE/ERN Number: Age and History Age of Clubhouse Buildings: Age of Greenkeeping Facility: Are the buildings in a good state of repair?: And are free from signs of subsidence?: Are the premises exposed to flood?: Are the premises permanently occupied?: Are any of the buildings listed?: If yes, what grade of listing?: Construction Type (i.e. Brick/Tile) Clubhouse: Greenkeeping Facility: Other buildings (Detail): Other Information - Please answer all questions Age of Electrical Wiring: Age of Plumbing: Has the Club conducted a Full Course Risk Assessment?: Health & Safety Policy in place?: Alarm Details/Security Clubhouse Burglar Alarm: Maintenance: Fire Alarm: Maintenance: Additional Physical Security: Greenkeeping Facility Burglar Alarm: Maintenance: Fire Alarm: Maintenance: Additional Physical Security: Other Buildings Burglar Alarm: Maintenance: Fire Alarm: Maintenance: Wage Roll Clubhouse: Greenkeeping: Clerical: Other: Turnover Members Subscriptions: Bar Catering & Clubhouse: Visitors & Guest Fees: Pro Shop: Other: Total: Gross Profit Bar & Catering: Declared Sums Insured Clubhouse Buildings: Greenkeeping Facility/Outbuildings: Other Buildings (Please specify): Walls Bridges & Fences (Limit of Loss)*: Greenkeeping Machinery & Equipment: Clubhouse and Shop Contents: Irrigation Equipment (Limit of Loss)*: Bar, Cellar & Food Stock: All Other Stock: Professional Shop & Other Retail Stock: Computer Equipment: Cups, Trophies, Art/Antiques: (Single Articles over £10,000): Laptops/Mobiles Phones (UK): Other Items (UK): Specified Items (UK): Money in Safe Limit Per Safe*: Total Money Limit Required*: If more than £5,000, please specify the make and model of the safe: Agricultural Vehicle Does the Club own any Registered Agricultural Vehicles?: * If Yes - What are the Registration Numbers and Vehicle Make/Model?: * Engineering Inspection: Pressurised Plant: Lifting Plant: Other - Please Specify: Directors and Officers: Cyber: HR: Additional Information: Declaration Neither the proposer, director or partner of the Trade or Business or its Subsidiary Companies a)has ever had a proposal refused or declined or ever had an insurance cancelled, renewal refused or had special terms imposed? b) have ever been convicted of or charged (but not yet tried) with a breach of any health and safety legislation or any other criminal offence other than parking or speeding offences or c) are subject to bankruptcy or insolvency orders which are either outstanding or have been discharged for less than 5 years? d) has been the subject of a County Court Judgement and/or ever been cited in any unsatisfied court judgements (or the Scottish equivalent) within the last 10 years? e) has been subject of an individual voluntary arrangement with creditors, voluntary liquidation, a winding up or administration order, or administrative receivership proceedings within the last 10 years?