Title
*
Please Select
Dr
Miss
Mr
Mrs
Prof
Rev'd
Name
*
First name
Last name
Date of birth
*
/
Day
/
Month
Year
Telephone
*
Please enter a valid phone number.
Email
*
Confirmation Email
Confirm email
Do you already hold insurance?
*
Yes
No
If yes, please advise your current insurance provide
Please advise your renewal date
-
Month
-
Day
Year
Date
Is a joint policy required?
*
Yes
No
Title
*
Please Select
Dr
Miss
Mr
Mrs
Prof
Rev'd
Name
*
First name
Last name
Date of birth
*
/
Day
/
Month
Year
Correspondence address
*
Address line 1
Address line 2
City
Postcode
Is the risk address the same as the correspondence address?
*
Yes
No
Risk address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select the option which best describes your business:
*
Please Select
Limited Company
Trading As
Sole Trader
How many acres does the land comprise?
*
From what date is cover required?
*
/
Day
/
Month
Year
Do you make an income from your smallholding or hobby farm?
*
Yes
No
If yes, please advise your total income
What activities will be taking place on the land e.g. keeping of own livestock?
*
Are there any lakes / ponds / watercourses on the land?
*
Yes
No
Please provide details
Are there any public footpaths or public rights of way on the land?
*
Yes
No
Is there a ménage or riding arena on the land?
*
Yes
No
Please provide details
What level of public liability cover do you require?
*
£2m
£5m
£10m
Do you require environmental impairment liability cover?
*
Yes
No
Do you require cover for your domestic property?
*
Yes
No
Is the property built of brick or stone with a tile or slate roof?
Yes
No
What is the rebuild value?
Is accidental damage cover required?
Yes
No
Do you require cover for the contents of your domestic property?
Yes
No
What is the replacement value?
Is accidental damage cover required?
*
Yes
No
Do you require cover for any outbuildings?
*
Yes
No
What percentage of the outbuilding(s) is Timber? (If multiple buildings, please list)
What is the rebuild value?
Are all outbuildings in a good state of repair, in active use, checked regularly and have no planned building works?
Yes
No
Do you require cover for any equipment?
*
Yes
No
What is the replacement value?
Do you require cover for accidental damge to underground pipes?
*
Yes
No
Do you require cover for your home?
*
Yes
No
Is your home listed?
Yes
No
Please select the best description of the home
Private dwelling
Holiday home
Holiday let
Fixed mobile home
Please provide the construction of your home
Please provide the rebuild value
Do you require cover for your home contents?
Yes
No
Please advise the replacement value of the contents
Do you require cover for any greenhouses?
*
Yes
No
Do you require cover for walls, gates, hedges and fences?
*
Yes up to £2,500
Yes up to £5,000
No cover required
If yes, please advise the replacement value
Do you require cover for any of the following:
*
Quad bike/ATV
Hired in plant
Machinery & implements
Horse/livestock trailer
Agricultural produce, deadstock and feedstuffs
Portacabins
Caravans and mobile homes
Saddlery & tack (max £10,000)
Contents of tack room
Contents of commercial premises
Agility equipment and show jumps
N/A
If yes, please advise the replacement value of each item you have selected above.
Do you require cover for machinery and implements?
*
Yes
No
Do you require cover for any livestock?
*
Yes
No
If yes, please detail the type, number and replacement value of each
Do you have any employees or voluntary helpers? Please note that you are legally required to arrange Employers' Liability for paid employees and for paid self-employed persons working under your direction.
*
Yes
No
Please state the employee or voluntary helpers activities
Please state the annual wageroll
Please state the Employee Reference Number (ERN) (if applicable)
Additional covers - Would you like your quote to include cover for any of the following:
Livestock
Farm property in transit
Loss of money (commercial)
Business all risks (e.g. deterioration of chilled stock, mobile phones, laptops)
Additional Public Liability extensions: (e.g. farmers markets, holiday lets, livery yards, camp site, B&B)
Business interruption
Have there been any claims made in the last 5 years?
*
Yes
No
If yes, please provide as much detail as possible.
Have there been any breaks in cover or significant periods of time where no insurance has been held on the property? If yes, please provide details.
*
How would you prefer to be contacted by Cliverton?
*
Phone
Email
How did you hear about Cliverton?
*
Please Select
Google
Social media
Advert
Trade show
Family or friend
Affinity partner
Other
Would you like to receive marketing material from Cliverton via email?
*
Yes
No
SUBMIT
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