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Your
Email address:
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Your
Name:
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Your
Address and Postcode:
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Your
Telephone Number:
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Your
Preferred Contact Method: |
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Company Details
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Your Company Trading Name:
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Your Trade: |
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your trade does not appear above, please give details here |
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Your Company Type: |
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Estimated annual wage roll |
Number of Staff |
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Clerical
Staff (including clerical principals):
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Manual Principals or directors:
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Other manual staff:
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Labour only subcontractors:
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Annual payments to Bona-fide subcontractors:
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Estimated annual turnover:
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How many full years have you been trading?
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Cover required |
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Policy start date required:
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(DD, Month, YYYY) |
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Employers Liability of £10 Million is automatic if you employ
somebody.
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Please indicate the Public Liability limit required:
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Do you require plant, machinery or tools cover?
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Additional Information (If you answer yes to any of the following questions, please provide full details in the space provided below.) |
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Do you work with asbestos or any other dangerous substances
(including white asbestos cement)?
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Yes No
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Do you engage in the application of heat (eg blowlamps, welding
or cutting equipment)?
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Yes No
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Do you work in any hazardous locations such as airports,
railways, refineries, power stations, spectator stands,
docks/piers, offshore installations and the like?
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Yes
No
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Do you work at heights greater than 15 metres?
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Yes No
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Do you work at depths below 1 metre?
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Yes
No
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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):
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you have any other comments relevant to your request, please
enter them in the box below: |
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| If
you would like us to send you details of other products
and services which might be of interest to you, please tick this
box:
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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.;
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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
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| Please
enter your name below to confirm that you have read and
understood the declaration
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Forenames:
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Surname:
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