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Contact Name: *
Business/ Trading Name:
Description Of Trade:
Address & Postcode: *
Date of Incorporation:
Registration Number:
Contact Telephone: *
Mobile Number:
Fax Number:
Email Address: *
How do you wish us to contact you:
Renewal Date /Start Date:
Renewal Premium:(£)
Is the company incorporated in England & Wales or Scotland under the Companies Act:
Has the company's name been changed in the last 5 years:
If YES, please list former name(s):

Cover Required

Turnover for last financial year: (£)
Pre-Tax profit / loss for last financial year: (£)
Net Worth: (£)
Has the company previously been insured? If YES, please provide the following:
Name of Insurers:
Premium: (£)
Indemnity Limit & Excess: (£)
Names of all current directors of the company:

How long has the business of the group been carried on by:

The Company:
Any predecessor:

Please state details of any shareholdings greater than 10% in any case of the company's issued shares (including directors interest):

Name of Shareholder:
Class of Share:
Do dealings in the company's share capital take place by virtue of a listing on a recognised stock exchange or under auspices of a recognised secondary market? If YES, please give details, if NO, please indicate if permission to deal would take place in the next twelve months:
Are there any proposals for the issue of shares (by way of sale or otherwise) by any group company:
Have any of the companies or businesses been acquired or disposed of by the group during the last 12 months, or (if earlier) since the date of the latest available group balance sheet or are there any such acquisitions or disposals currently under consideration:
Are there any proposals of which the company is aware, which might involve any group company being acquired by or merged with any other company:
Please provide details of all subsidiaries in the US / Canada not wholly owned by the company:
Please provide details of all persons (included those listed previously) who are Directors, Executive Officers of the company's subsidiaries in the US / Canada. If a person holds more than one office/ position all should be listed:
Does the group have any stock, shares or debentures traded in the USA / Canada:
Does the group have any debt or equity instruments, or commercial paper in the US/ Canada:
Please state the book value of total gross assets of the group in the USA / Canada:
What is the total number of employees in the USA / Canada:
Has the company ever been refused this type of insurance or had similar insurance cancelled:
If any insurance similar to that now proposed has been or were now in effect, would any claim which has been made or which is now pending against any person proposed for insurance have fallen within the scope of such insurance:
Is the company or any person proposed for insurance aware, after enquiry, of any circumstances or incident which it or he has reason to suppose might afford grounds for any future claim that wouldfall within the scope of the proposed insurance:
State Limit of Indemnity required:


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W E Bedford Insurance Services (Wimbledon) Ltd, Trident Court, Oakcroft Road,
Chessington, KT9 1BD is authorised and regulated by the Financial Conduct Authority.
Our FCA Register number is 305737