Business Name:
Are you a Limited Company:
Contact Name - Title & Surname:
Contact Name - First Name:
Business Address:
Contact Number:
E-mail Address:
Renewal Date:
Name of Existing Insurers:
Target Premium (£):
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:
Limit of Indemnity:
Estimated Annual Turnover (£):
Details of Any Work Outside of U.K.:
Limit of Indemnity:
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:
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:
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