lAND lIABILITY ENQUIRY FORM

PLEASE EITHER COMPLETE THE FORM BELOW OR SEND YOUR PRESENTATION TO [email protected]

Name of Brokerage and/or Matrix Broker reference (eg AB1234) *

Email *

Proposer Name *

Risk Address *

Use of Land *

How long has the proposer owned the land? *

Please provide details of any claims history *

Limit of Indemnity *

Legal Status of Business *

Are there any ponds, lakes, rivers or other water sources within the boundaries of the premises *

If answered Yes to the question above please describe

Are there any rights of way within the boundaries of the premises *

If answered Yes to the question above please describe

Has the land suffered problems with vagrants, squatters or vandals recently *

If answered Yes to the question above please describe

Are there any buildings on the premises *

If answered Yes to the question above please describe

Is the premises or land owned by the council *

If answered Yes to the question above please describe

Target Premium

Does the proposer have any adverse financial history including but not limited to Liquidations, bankruptcy's, CCJ's, criminal convictions or pending prosecutions *

If answering yes to the question above please provide details

Has an insurer ever refused to renew or cancelled my/our policy or imposed special terms *

If answering yes to the question above please provide details

Any other information