Insurance and Financial Services
for the Dental Profession

To discover the benefits of insuring your property through BDA Plus, simply complete the brief details below and we will contact you with a quotation.

You

Salutation *	Please Select Mr Mrs Ms Miss Dr
Forename *
Surname *
Date of birth *
Address *
Postcode *
BDA Member *	Please Select Yes No
Telephone *
Email Address
Mobile
What prompted you to visit our website? *	Please select BDA Conference BDA News BDA News Insert Steamline dedupe The Dentist Magazine Mailing - Brand Mailing Mailing - Prospect Mailing - Membership Insert Google BDA Website PR Activities Word of mouth

The Property

Risk Address
Risk Postcode
Are you the sole owner? *	Please select Yes No
If no, please provide details of other owners
Other owner 1
Name
Date of birth
Relationship to proposer
Occupation
Other owner 2
Name
Date of birth
Relationship to proposer
Occupation

How long has the property been owned? *	months/years
What is the use of the property? *	Please Select Residential Commercial
Will the property be unoccupied at any stage? *	Please Select Yes No
If yes, for approximately how long will the property be unoccupied? *	weeks/months
If yes, why is the property unoccupied? *	Please Select Renovation Demolition For Sale Awaiting Tenants

Type of Property *	Please select Detached Semi Detached Terraced Bungalow Flat Other
Year of Construction
If a house, number of bedrooms?	Please select 1 2 3 4 5 6 6+
Wall construction material *	Please select Brick Stone Timber Metal Frame Metal Clad Cobb Glass
Roof construction material *	Please select Tile Slate Wood Thatch Glass Metal Clad
Is there any flat roof areas on the property? *	Please select Yes No
If yes, what percentage of the roof is flat?	%
If yes, what material is used on the flat roof?	%
Floor construction material? *	Please select Brick Stone Concrete Timber
Stairs construction material? *	Please select Brick Stone Concrete Timber
Is the property subject to any preservation orders? *	Please select Yes No
If yes, which? *	Please select Grade 1 listed Grade 2 listed Conservation Area
Is the property free from heave, landslide and subsidence? *	Please select Yes No
Is the property free from flooding? *	Please select Yes No

Have you or any partner or Director ever:

Been declared bankrupt, insolvent or disqualified from being a company director?	Please select Yes No
Been convicted or charged or given an official police caution in respect of any criminal offence, other than a motoring conviction?	Please select Yes No
Had any county court judgements or sheriff court decrees in the last 5 years?	Please select Yes No
Had any insurance proposal declined, renewal refused, special or increased terms or had insurance cancelled mid term?	Please select Yes No

Security & Occupancy

Do all external doors (and internal doors if premises is not solely occupied by you) have 5 lever mortice deadlocks? *	Please select Yes No
Do all accessible windows, fanlights and skylights have key operated locks? *	Please select Yes No
Is the property protected by an intruder alarm system *	Please select Yes No
Do you accept refferals from the DSS or Students? *	Please select Yes No

Cover Details

Rebuilding value of the property *
Contents sum insured *
Landlord's contents *
Contents in communal areas *
Loss of rent receivable *
Period	Please select 12 months 24 months 36 months
Public / Property Owners Liability limit	Please select £1m £2m £5m
Employers Liability cover required	Please select Yes No
Cover required	Please select Standard Accidental Damage
Additional cover required	Subsidence Terrorism

Claims

Have you suffered any claims in the last 5 years *	Please select Yes No
If yes, please give details of dates, incident and costs

General Information

Existing Insurer *
Renewal Date *
Current Premium *

*Denotes compulsory field

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