COMPANY DETAILS
Company Name:
Contact Name - Title & Surname:
Contact Name - First Name:
Business Address:
Postcode:
Contact Number:
E-mail Address:
Business Description:
Number of Years Trading:
Renewal Date:
Target Premium (£):
COVER REQUIRED
Insured Persons:
If Named, please give details:
Period of Cover:
Territorial Limits:
Clerical/Managerial Wage Roll (£):
No of Clerical/Managerial Employees:
Manual Wage Roll (£):
No of Manual Employees:
Details of Work Away From Premises:
Additional Information:
Details of Work Outside of U.K.:
ADDITIONAL INFORMATION
Please provide details of ALL and ANY losses you have suffered or claims you have made in the last five years (please advise date(s), cost(s) and circumstances:
Any additional information/comments or material facts that may affect an insurers willingness to offer cover:
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