PFM Dental

SURGERY INSURANCE QUOTATION REQUEST FORM

Please complete the form to enable us to provide you with a quotation for your surgery insurance.

PERSONAL DETAILS
Title:
Name:
Date of Birth:
Occupation:
GDC Number:
Correspondence Address:	Practice Address (to be insured):
Postcode:	Postcode:
Telephone No.:	Telephone No.:
Email Address:

SUMS INSURED
Buildings:	£
Surgery Contents:	£
Computers:	£
Laptops:	£
Loss of Fees:	£
Number of autoclaves:
Number of compressors:
Total number of pressure vessels:
Do you require pressure vessels inspection to be included?

POLICY INFORMATION

Renewal Date / Required Date:

Current Insurer, if applicable:

Existing Premium, if applicable:

How long have you owned the practice?

Have you no claims? If so, how many years?

CONSTRUCTION
Year property built:
Are the premises purpose built?
Any History of Subsidence?
Any history of flooding?
Standard Construction?
Are all floors concrete?

SECURITY

Does the practice have the following:

Intruder Alarm installed? Is it NACOSS Approved? Is it a signalling alarm?

CCTVs insalled?

5 Lever Mortice Deadlocks (on all external doors)?

Window locks (on all external windows)?

Does anybody else occupy the premises?

Is the practice self contained?

Please give information on occupany:

ADDITIONAL INFO

Please provide any additional relevant information:

CLIENT DECLARATION

I hereby authorise and request Practice Financial Management Ltd to obtain a quotation for home surgery based on the information that I have provided.

I confirm that the above information is true and correct to the best of my knowledge and that all material facts have been disclosed. I understand that if this is not the case that the insurance policy may be invalid. I also realise that if there are any changes to my circumstances, that I must inform Practice Financial Management Ltd or your selected insurer.

I have read, and agree to, the above declaration