Personal Details

Your Email address:
Your Name:
Your Address and Postcode:
Your Telephone Number:
Your Preferred Contact Method:	Telephone Email Post
Company Details
Your Company Trading Name:
Your Trade:	Please select Activity Centre / Corporate HospitalityAmusement / Theme ParkAmusement ArcadesBingo HallsBowling Ten PinCaravan Parks including Holidays Homes and CampsCasinosCastlesChildren’s Indoor Play AreaCinemasCircusesConcert Venues – OutdoorConcert Venues / Halls – IndoorDisco / Nightclub / Themed BarsFootball ClubsGreyhound TracksHealth & FitnessHorse Racing VenuesHotelsPop Concerts - IndoorPop Concerts - OutdoorPublic HousesRestaurants and Eating PlacesRugby ClubsShort Events (Sports)Snooker and Billiard HallsSports StadiumTheatresTour OperatorsWildlife Parks & Zoos
Your Company Type:	Please select Limited Company Partnership Sole Trader
Annual Wageroll - Clerical employees:
Annual Wageroll - Doorstaff:
Annual Wageroll - All other employees:
Estimated annual turnover:
How many full years have you been trading?
Cover required
Policy start date required:	(DD, Month, YYYY)
Please indicate the Employers Liability limit required:	Please select Not Required £10 Million
Please indicate the Public Liability limit required:	Please select £1 Million £2 Million £5 million £10 million
Please supply details of any claims or incidents that may lead to a claim in the last 5 years (including date and nature of incident and any amounts paid or outstanding):
If you have any other comments relevant to your request, please enter them in the box below:
If you would like us to send you details of other products and services which might be of interest to you, please check this box:
Declaration
By submitting this form: I/We agree that if this insurance is completed, the protections and/or safeguards mentioned herein shall not be withdrawn or varied to the detriment of Underwriters without their consent.; To the best of my/our knowledge and belief, all the information provided in the Proposal Form is true and I/We have not withheld any material facts. I/We understand that non-disclosure or misrepresentation of a material fact will entitle Insurers to void the insurance.(N.B. A material fact is one likely to influence acceptance or assessment of this proposal by Insurers. If you are in any doubt as to what constitutes a material fact, you should consult your Insurance Broker).;  I/We understand that the signing of this Proposal Form does not bind me to complete the Insurance but agree that, should a Contract of Insurance be concluded, this Proposal and the statements made therein form the basis of the Contract
Please enter your name below to confirm that you have read and understood the declaration
Forenames:
Surname: