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CommercialRetail Proposal

Retail Proposal Form

Retail PolicyOur Retail Policy takes a broad and flexible view of retailer’s insurance needs providing

cover in respect of:

• Property damage

• Financial Loss

• Legal Liabilities

A comprehensive Standard Cover package is provided in addition to which Optional

Covers are also available. It is appropriate where sums insured on buildings are below

€1,300,00 and €635,000 on Contents.

Major benefits include:

• Broad cover in one convenient flexible policy

• One premium and one renewal date

• Facility to pay annual premium by instalments via our payment plan

• Cover on All Risks or Selected Perils basis.

Property Damage

Buildings and Trade Contents

Depending on requirements, cover can be provided on a“Fire and Specified Perils” (e.g. Flood, Storm, Theft, etc.) orwider “All Risks” basis. Modern Clauses and Wordingsapply.

Breakage of glass/sanitary ware, professional fees, debrisremoval, public authorities requirements, delivery of goodsto customers, service pipes and cables, T.V., radio aerialsand masts, temporary removal/extension, loss of keys andtenants liability to landlord and workmen are includedautomatically.

Our Retail Policy also offers the following OptionalCovers:

Deterioration of Frozen FoodCover can be provided for deterioration orputrefication of food in refrigeration cabinets at thepremises up to a limit of €1025 per cabinet (therefrigerators must not be over 10 years old and amaintenance contract must be in force).

Household ContentsIf you live on the premises, cover can be extendedto protect your domestic contents.

All Risks cover on Neon /Illuminated Signs

All Risks cover on business equipmentIf otherwise covered on a Fire and Specific Perilsbasis, cover can be extended to All Risks onbusiness equipment or signs/non standard glass.

Brief Summary of Cover

BenefitsOur Retail Policy delivers:

• Broad cover in one convenient flexible policy.

• One premium and one renewal date.

• A discount for retailers in shopping centres.

• Convenient support from our strategically located branch network.

• The benefit of Sums Insured on trade contents being automatically increased by 25% at

Christmas and Easter free of charge.

• Claims on a “new for old” basis.

• A first class claim service.

• Facility to pay annual premiums by instalments via our payment plan.

Financial LossOur Retail Policy provides two essentialFInancial Covers:

Business InterruptionThis cover which protects againstreduction/loss of profits when business isinterrupted due to Fire or other insured perils.

Loss of MoneyLoss by robbery, theft or certain other causeswhilst at the business premises, in transit orwhilst at the home of employees insured up tospecific limits.

Cover is extended to include cover for PersonalAssault on any principal or employee arisingout of an attempt to steal money or otherinsured property (details of cover are availableupon request).

Legal LiabilitiesOur Retail Policy covers your legal liabilities inrespect of:

Employeesfor injury or disease sustained by them in thecourse of their employment. Indemnity is€13,000,000 Any One Event.

Members of the Publicfor injury or disease or damage to property arising out of the business including the sale andsupply of goods. Indemnity limit is €2,550,000both for public and products liability.

Wrongful Arrest by youthis covers your legal liability to pay damages forWrongful Arrest arising out of shoplifting orstealing at the premises, (limit of indemnity€12,700).

In addition our Retail Policy covers legal costsand expenses incurred with our consent.

Brief Summary of Cover (continued)

30 PRO 03.08 TF

Allianz p.l.c., Allianz House, Elmpark, Merrion Road, Dublin 4.Telephone: (01) 613 3000 Fax: (01) 613 4444Email: info@allianz.ie Website: www.allianz.ieAllianz p.l.c. is regulated by the Financial Regulator. Registered in Ireland, No. 143108

PLEASE ANSWER ALL QUESTIONS FULLY AND ACCURATELY AS FAILURE TO DO SO MAY RENDER YOUR POLICY VOID.

General DetailsPLEASE COMPLETE IN BLOCK CAPITALS

Name of Proposer:

Postal Address:

Business Address:

Type of Business (describe fully):

Retail Proposal Form

Yes NoGeneral Questions1. Do you:

(a) or any of your employees reside on the premises outside of business hours?(b) sell jewellery, watches, gold or silver articles, precious metals, precious stones or furs?(c) sell flammable oils or spirits or other hazardous goods?(d) undertake work away from the premises other than deliveries?

2. Have you:(a) previously sustained a loss in connection with any of the insurances for which you now want

cover?(b) been previously insured?(c) ever had a proposal declined?(d) ever had special terms or conditions imposed?

3. Are the Premises in an area which is subject to flooding or storm damage?

4. Are the Premises:(a) Built of brick, stone or concrete and roofed with slates, non-combustible tiles, concrete, metal,

asphalt or asbestos?(b) in a good state of repair and will they be so maintained?(c) heated by a conventional hot water system, electricity, gas appliances using gas from a public

supply or ordinary solid fuel fires?

4. Is all stock which is stored below street levels on racks at least 1 foot (300mm) off the floor?

6. Do you keep records of stock, sales and purchases which are regularly audited?

7. Are you the sole occupier of the building?If you have ticked any shaded boxes, please give further details here

8. Please state number of full time assistants.

9. Date cover to commence

General Details (continued)10. Minimum Security Requirements:

Are all external doors fitted with 5 lever mortice deadlocks or roller shutters?Are all accessible windows fitted with window locks, bars or grilles?Burglar Alarm?If so, is there a Central Station Connection?

Name of Alarm CompanyN.B. Please include a copy of the Burglar Alarm Specification with your completed proposal form,

otherwise full cover may not be granted

11. Please indicate the total number of employees: 0-4 , 5-7 , 8-10 , 11 + (specify)

12. Please specify the name(s) and address(es) of any interested party that require their interest to be noted on the policy.

Name:

Address:

Cover Requirements

A. PROPERTY DAMAGEType of cover required (please tick appropriate box)

1. Buildings (including landlord’s fixtures and fittings, walls, gates & fences, professional fees, debris removal costs & Public Authority compliance costs.

2. Trade Contents(a) business fixtures & fittings, machinery, books, manuscripts, documents,

employees personal effects, interior decorations & tenants improvements.(b) stock in trade and goods in trust (other than separate stock below) (c) tobacco and cigarettes, (d) wine and spirits, (e) cameras, photographic, radio and television equipment (f) other (give details) Total Trade Contents

All standard glass and fixed sanitary ware are covered automatically.Additional cover for non-standard glass can be covered under All Risks section.

3. Optional Cover:(a) Deterioration of Frozen Food. State number of cabinets containing Frozen Food.

Limited required per cabinet (up to €1025)Total cover required for Frozen Food

(b) All Risks (i) Neon or illuminated signs or non standard glass (description/wording):

1.2.

(ii) Business machines (only required if policy is on a Fire/Additional Perils basis).1.2.

(c) Household Contents

Fire/Additional Perils

Sum Insured

€

“All Risks”

Premium (office use only)

€

Yes No

Important NoticeFailure to disclose material facts could result in your Policy being invalidated. Material facts are those facts which influence theacceptance or assessment of your Proposal. If you are in any doubt as to whether a fact is material you should disclose it.Before you complete the declaration, please check that;(a) You have selected the necessary cover.(c) If you are registered for VAT any claim for loss or damage to property will be paid exclusive to VAT, and you are advised to

arrange your sums insured accordingly. Allowances should be made to include an amount for VAT in the sum insured, if you are not registered.

(d) The sums insured, values and limits requested are adequate.Certain Sections of the policy are subject to underinsurance clauses (see policy for full details) which mean that if the sum insuredspecified for an item is less than its actual value, the amount you recover following a loss will be proportionately reduced.

DeclarationPlease read the following declaration very carefully, especially if the proposal has not been completed in your own hand.

I/We declare that the statements and particulars contained in this proposal and any supplementary statements and particulars supplied byme/us in connection with this proposal are to the best of my/our belief and knowledge true and no material facts concerning the insurancehave been withheld. I/We agree that this proposal and declaration shall be the basis of the contract between me/us and Allianz p.l.c., andI/We agree to accept a policy in the Company’s usual form for these classes of Insurance and to provide at the end of each period of insuranceinformation as required by the Company concerning those Insurances which are on an adjustable basis and to pay such additional premiumsas may be required. I/We understand that no cover will apply until this proposal has been accepted by the Company and cover confirmed.

Signature: Date:

Note: Each section of the Policy is subject to Exclusions and Conditions and a specimen policy is available on request.

We recommend that you should keep a record, including copies of letters and this proposal form, of all information supplied to us for thepurpose of entering into this insurance contract. Please let us know if you would like a copy of this proposal form sent to you.

B. FINANCIAL LOSSBusiness Interruption**The standard policy covers loss of gross profit up to an amount equal to twice the sum insured on Trade Contents for an Indemnity period of 12 months 18 months 24 months (please tick period required)

Please complete the following if the Standard Sum Insured is insufficient for your needs.

Annual SalesLess cost of goods soldGross profitAdd % for growth in businessSum insured for 12 month indemnity(**Please ensure the above represents the Indemnity Period requested.)Loss of Money is covered automatically, details of limits are available upon request.

C. LEGAL LIABILITIESStandard cover is provided for your Legal Liabilities including:1. Employers Liability. 2. Public Liability. 3. Products Liability. 4. Wrongful arrests by you.For further details please refer to the Retail Policy brochure

4. Have you or your partner, or any director or principal of the Company, ever been convicted of a criminal offence?Yes NoIf Yes, please give details:

Cover Requirements (continued)

€

Sum Insured €

Premium (office use only)

€

30 PRO 03.08 TF

Allianz p.l.c., Allianz House, Elmpark, Merrion Road, Dublin 4.Telephone: (01) 613 3000 Fax: (01) 613 4444Email: info@allianz.ie Website: www.allianz.ieAllianz p.l.c. is regulated by the Financial Regulator. Registered in Ireland, No. 143108