Liability Insurance Quote Request Form

Insurance2day Insurance Services Ltd are authorised and regulated by the Financial Services Authority and are members of:

Business Name:

Are you a Limited Company:

Yes

Contact Name - Title & Surname:

Contact Name - First Name:

Business Address:

Postcode:

Contact Number:

E-mail Address:

Renewal Date:

Name of Existing Insurers:

Target Premium (£):

BUSINESS ACTIVITIES

Date Business Established:

Description of Business Activities:

Type of Premises Worked at:(i.e. Residential, Commercial &/or Industrial, please give examples)

Maximum Height Worked at:

Maximum Depth Worked at:

Details of Any Heat Processes Undertaken:

PUBLIC LIABILITY

Limit of Indemnity:

Estimated Annual Turnover (£):

Details of Any Work Outside of U.K.:

EMPLOYERS' LIABILITY

Limit of Indemnity:

Clerical/Managerial:

Est. Annual Wage Roll (£):

Number of Clerical Only:

Manual Workers:

Est. Annual Wage Roll (£):

Number of Manual Workers (inc. proprietor if manual worker):

Est. Annual Payments Sub-Contractors:

Bona Fide (£):

Labour Only (£):

Max Number of Labour Only:

ADDITIONAL INFORMATION

Do You Have a Written Health & Safety Policy:

If YES, is it provided and updated by an external Health & Safety consultant?

Do You Issue & Record Issue of Personal Protective Equipment?

Please Give Details of ALL and ANY Claims/Losses You Have Suffered In The Past 5 Years:(please advise date(s), cost(s) and circumstances)

Have You Ever Had an Insurance Policy Cancelled or Special Terms Imposed?

Any Additional Information/Comments:

Thank you for completing your details - please press the submit button for a quotation.