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Name |
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Address |
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Town |
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Postcode |
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Email Address |
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Telephone |
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Mobile |
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Business Description |
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Legal Status |
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Date Business Established |
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Cover
Required |
Public
Liability |
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Sales and
Service Indemnity |
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Employers
Liability |
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| Location |
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Does
your work involve the application of heat? |
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Partners/Directors – manual |
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Partners/Directors - non-manual |
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Employed family members – manual |
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Employed family members – non-manual Clerical/administrative |
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All others (including sales) |
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Annual Turnover
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Have the Proposer(s), or any Partner(s), or
Director(s) ever:
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a) Had any proposal for insurance cancelled /
declined to renew / require increased premium or special terms?
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b) Been prosecuted or are any prosecutions
pending under the Health and Safety at Work Act or any other
statute or regulation?
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c) Been convicted of, prosecuted for or are
any prosecutions pending for any criminal offence (other than
motoring convictions)?
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Claims |
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Has the Proposer suffered a loss, claim or
incident (which may give rise to a claim) at these premises, or
any other premises, whether insured or not in the last 5 years?
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| If YES to any of the above, please give full details: |
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