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Proposer's Full Name(s): (enter sole trader's name or all partner's names if a partnership) | |
Limited Company Name: (if operating as a limited company) | |
Trading Name/Trading As: (if different to the above) | |
Trading Status: | |
Business Address: | |
Postcode: | |
Daytime Telephone Number: | |
*E-Mail Address: | |
*Please note that your email address will only be used to provide you with your quote and not for any other marketing purposes. |
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Have you, or any other partner or director ever been convicted of or charged (but not yet tried) with any criminal offences other than a motoring offence? | Yes No |
If yes, please provide details: (e.g. type of conviction(s), date(s) of conviction(s), details of any fines and/or length of custodial sentence(s)) | |
Has any insurer ever refused renewal, declined/cancelled cover or imposed any special terms? | Yes No |
If yes, please provide details: (e.g. details of any insurance refused/ cancelled/special terms imposed, etc.) | |
Have you, or any other partner or director ever had any County Court Judgements (CCJ's) / sheriff decrees / IVA's or ever been declared bankrupt, or involved in a company which has become insolvent or which has gone into liquidation, receivership or administration? | Yes No |
If yes, please provide details: (e.g. date(s) of bankruptcy/insolvency/CCJ/IVA, amount of bankruptcy/insolvency/CCJ/IVA (£'s), date bankruptcy discharged / date CCJ/IVA settled, circumstances of bankruptcy/insolvency/CCJ/IVA, etc.) |
Please note we are unable to provide a quote if your bankruptcy is not discharged or your CCJ / IVA remains outstanding or unsettled. |
Have you, or any other partner or director ever been prosecuted or served a prohibition or improvement order by the Health & Safety Executive? | Yes No |
If yes, please provide details: (e.g. date of prosecution(s), details of offence(s), etc.) | |
Have you, or any other partner or director ever been the subject of a recovery action from HM Customs and Excise or the Inland Revenue? | Yes No |
If yes, please provide details: (i.e. name of person or business subject to recovery action, date of recovery action, and reason for the recovery action) | |
Business Activities |
Description of your work activities: (Please describe as fully as possible) | |
Are you a member of any trade association? | Yes No |
Please give details of any trade association you are a member of: (including membership number) | |
Is your home the base for your business or are you operating from separate dedicated business premises? | |
Is any work undertaken outside of the U.K.? | Yes No |
If yes, please provide details: (i.e. area and percentage of time outside UK) | |
Years Trading / Experience |
How many years has your business been trading? | |
Number of years experience (if different) | |
Height Details |
Please state the maximum height you work to: | metres |
Do you use any slings, harnesses or cradles? | Yes No |
If yes, please provide details: | |
Work Locations |
What percentage of your work is carried out at the following locations: |
Private Dwelling Houses and Flats: | % |
Commercial Buildings (shops, offices, etc.): | % |
Pubs, Hotels and Schools: | % |
Hospitals: | % |
Industrial Buildings (factories, warehouses, etc.): | % |
Any Other Locations other than above (please specify):
| % |
Total: | 100% |
Hazardous Locations |
Do you carry out work at any hazardous locations? (Hazardous locations are generally defined as on or at airports, aeroplanes, oil/petrol/gas or chemical storage tanks, offshore gas or oil installations, gas or chemical works, nuclear processing installations, railways, tunnels, chimney shafts, collieries, docks, gas works, harbours, mines, oil refineries, power stations, dams, ships, steeples, towers, viaducts, quarrys, dams, hospital operating theatres and clean room environments.) | Yes No |
Please provide details of hazardous loctions worked at: | |
Work Activities |
Please state the percentage split of your work activities: |
Internal Cleaning-Domestic Premises: | % |
Internal Cleaning-Commercial Premises: | % |
Internal Cleaning-Industrial Premises: | % |
Builders Cleans: | % |
Carpet / Upholstery Cleaning: | % |
Machinery Cleaning (please state type of machinery below)
| % |
Window Cleaning (ground level / reach & wash): | % |
Window Cleaning Up To 10 Metres (ladders, etc.): | % |
Window Cleaning Over 10 Metres: | % |
Pressure Washing & Jetting: | % |
Any Other Work other than above (please specify below)
| % |
Total: | 100% |
Antiviral Disinfectants |
Do your business activities include applying chemical antiviral disinfectants to production areas as fogs or mists? | Yes No |
Hazardous Cleaning Activities |
Do you carry out work: |
(i) In hospital operating theatres, or clean room environments? | Yes No |
(ii) Involving the removal of clinical waste, sharps or needles? | Yes No |
(iii) Involving the cleaning or surgical instruments, surgical clothing, or electrical or mechanical medical equipment? | Yes No |
(iv) Involving the cleaning of kitchen canopies, extraction equipment, ducting or grease traps? | Yes No |
(v) Involving stone, tank or boiler cleaning or use of high-pressure equipment? | Yes No |
If yes, please provide details including type & method of work, equipment and chemicals used, maximum PSI etc.: | |
(vi) Involving the use of pressure washing equipment at a pressure greater than 2,000 psi? | Yes No |
If yes, please provide details including type & method of work, and the maximum PSI used, etc.: | |
(vii) Involving the cleaning of business computers? | Yes No |
(viii) Involving any confined space work? | Yes No |
If yes, please provide details: (incl. percentage of work this represents) | |
(ix) Any crime scene work? | Yes No |
If yes, what percentage of your work? | |
Health & Safety / Claims Experience |
Do you have a written Health & Safety Policy which is regularly updated and shown to employees? | Yes No |
Claims History / Experience |
Have you or any other partner or director suffered any loss or had any claims made against you in the last 5 years? | Yes No |
If yes, please provide details: | |
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Public/Product Liability |
Public/Product Liability limit of indemnity: | | |
| | Manual Principals | | Non-Manual/ Clerical Principals |
Number of Proprietors/Partners/Co. Directors: | No. | | No. | |
Annual Wages of Proprietors/Partners/Co. Directors: | | | | |
Do you use Bona Fide Sub-Contractors? (BFSC's are sub-contractors who supply their own equipment/ materials on site and hold their own public & employers' liability insurance) | Yes No |
If yes, please state your annual payments to Bona-Fide Sub-Contractors (BFSC's): | | | | |
Type of activities carried out by BFSC's: | |
Employers' Liability (Compulsory by law if you directly employ staff or labour only sub-contractors) |
Is Employers' Liability Cover Required? (£10M cover provided as standard) | | |
| | Manual Employees | | Non-Manual/ Clerical Employees |
Number of Employees/Labour Only Sub Contractors: (Do not include proprietors, partners or directors) | No. | | No. | |
Total Annual Wages of Employees/LOSC's: | | | | |
Employers' Reference Number (optional) |
Employers' Reference Number (ERN) (if available): | (e.g. 123/AB12345 or 'Exempt') |
Turnover |
Estimated Annual Turnover for next 12 months: | | |
Do you manufacture or supply cleaning consumables/equipment or janitorial products? | | Yes No |
Estimated Turnover in respect of cleaning/janitorial products sold/supplied only: | | |
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The following optional covers may available at additional premium if required: |
Do you require cover for damage to Property / Item(s) Being Cleaned? | | Yes No |
Do you require cover for Treatment Risks? (e.g. damage to carpets, soft furnishings, etc. caused during cleaning using cleaning chemicals) | | Yes No |
Do you require cover for Loss of Keys? (only applicable if you hold keys for your customers) | | Yes No |
If yes, limit of indemnity required: | | |
Do you require cover for Business Equipment? | | Yes No |
Please confirm the sum insured required: | | |
Is cover required for Fidelity Guarantee? (i.e. provides cover for theft by employees) | | Yes No |
If yes, limit of indemnity required: | | |
Is cover required for Financial Loss? (i.e. provides cover if a third party suffers financial loss/ business interruption without property damage or injury being caused, e.g. unable to access business premises, etc.) | | Yes No |
If yes, limit of indemnity required: | | |
Do you require Business Legal Expenses Cover? | | Yes No
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Limit of indemnity required?: | | |
Has the business been involved in any legal disputes, employment disputes or tax investigations in the last 5 years? | | Yes No |
Do you require Directors and Officers Cover? (limited companies only) | | Yes No
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Limit of indemnity required?: | | |
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Additional Information / Cover |
If there is any additional information that you wish to disclose or cover that you wish to include, please provide details: | |
You are required to make a fair presentation of the risk to insurers which means that you are required to disclose every material circumstance which you know or ought to know relating to the risk to be insured. Materially important information is any information that could influence an insurer's decision to accept your risk including the cost of your insurance. Failure to comply with the duty of fair presentation could mean that your policy is void or that insurers are not liable to pay all or part of your claim(s). By submitting this quotation you are confirming that there are no other material facts to disclose other than those shown above. |
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Cover Start Date / Renewal Date: | | |
Current Annual Premium / Best Quotation: | | This may help us to get you a better quote |
Current / Previous Insurer: | | e.g. Aviva, AXA, Allianz, QBE, RSA, Zurich, etc. |