General (Continued)
Have you ever traded in another name? If yes, please give details including dates and business description:
Do you have any other business interests? If yes, please give details
 
Are you now, or have you previously been insured against any of the risks proposed?
Yes No
Insurer
 
Have any Insurers ever:
a) Declined your proposal (If yes, give details)
b) Refused to renew or cancelled your Policy
c) Imposed special conditions
 
Have you sustained any loss or damage during the last 5 years which would have been covered by this type of policy had it been in force:
DateCircumstancesAmountStatusInsurer
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Registered in England: Number 608819
Authorised and Regulated by the Financial Services Authority
Registered Office:
Lygon House, 50 London Road, Bromley, Kent. BR1 3RA