Company Name:
Contact Name - Title & Surname:
Contact Name - First Name:
Business Address:
Contact Number:
E-mail Address:
Cover Required
Legal Expenses
Limit of Indemnity

For companies with an estimated annual
turnover up to £1 million

With Employers Protection Without Employers Protection
£50,000 £115 £90
£100,000 £130 £105
Estimated Annual Turnover (£):
Details of Any Other Cover Required:
Method of Payment
If Other, please give details
Inception Date:
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 to request cover