Details

Contact Name:*

Number of Years Trading:

Description of Business/Trade:

Address & Postcode:*

Company Status:

Contact Telephone:*

Mobile Number:

Email Address:*

Fax Number:

How do you wish us to contact you:

Cover Required

Public Liability:

Employers' Liability:

Number of manual principals:

Number of manual staff:

Number of clerical staff:

Annual Wageroll manual:

Annual turnover clerical:

Total Annual Turnover:

Any claims in the last 5 years:

If yes, please state approximate dates, causes of claim and amounts paid:

Number of years experience:

Tools Cover required:

(Please note that cover between the hours of 9pm and 6am is not operative unless tools are placed in a locked compound or taken to your place of residence)

Current Insurer:

Renewal Date / Start Date:

Renewal Premium: £