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Proposer's Full Name(s): (enter sole trader's name or all partner's names if a partnership) | |
Contact Name: (if different to proposer's name) | |
Limited Company Name: (if operating as a limited company) | |
Trading Name/Trading As: (if different to the above) | |
Trading Status: | |
Business Address: | |
Postcode: | |
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/reason for conviction(s), date(s) of conviction(s), details of any fines and/or community service (if applicable), length of custodial sentence(s) (if applicable),etc.) | |
Has any insurer ever refused renewal, declined or cancelled cover or imposed any special terms? | Yes No |
If yes, please provide details: (e.g. details/reason for any insurance refused/cancelled/special terms imposed, etc.) | |
Have you, or any other partner or director ever had any county court judgements / sheriff decrees / IVA's or 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, date bankruptcy discharged or CCJ/IVA settled, circumstances, 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 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) | |
Details of Business Activities |
Description of your work activities: (Please describe as fully as possible including a percentage split between each activity, where you carry out more than one activity) | |
Does any of your work involve soil sampling, geological work, piling, tunnelling, or any other work an exposure to damage to underground services? | Yes No |
If yes, please provide details of the work: (e.g. type of work undertaken and length of these contracts) | |
Trade Associations / Accreditations |
Are you a member of a trade assocation, and/or do you have any trade accreditations? (e.g. CITB, Constructionline, etc.)? | Yes No |
If yes, please provide details: | |
Premises / Locations Worked At (away from your own premises) |
What percentage of your turnover is carried out at the following premises / locations: |
(i) Private Dwelling Houses and Flats: | % |
(ii) Commercial Premises (e.g. shops, offices, pubs, etc.): | % |
(iii) Industrial Premises (e.g. industrial units, factories, etc.): | % |
(iv) Other Premises/Locations (specify below if applicable) : | % |
Total: | 100% |
Is work carried out at any hazardous locations? (These can include, but are not limited to; railways, motorways, bridges, viaducts, power stations, nuclear installations, oil, gas or petrochemical refineries, aircraft/airports/airside, quarries, mines, watercraft/ships, docks, harbours, piers, dams, towers, steeples and offshore installations.) | Yes No |
If yes, please state type of location(s) and the percentage of work spent at the location(s): | |
Is any work undertaken outside of the U.K.? | Yes No |
If yes, please provide details: (i.e. area / country worked at, type of contract(s) undertaken, and percentage of turnover this work represents) | |
Heat Use |
Do your activities involve the use of heat? (e.g. angle grinders, blow lamps, welding equipment, heat guns, etc.) | Yes No |
If yes, please state the type of heat used: (e.g. angle grinders, blow lamps, welding equipment, heat guns, etc.) | |
Please confirm the percentage of time it is used: | |
Will heat work include the use of welding or flame cutting equipment? | Yes No |
Details of Depth Work |
Please confirm the maximum depth you would work: | metres |
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Approximate percentage of work up to 1 metre depth: | % |
Approximate percentage of work 1 to 3 metres depth: | % |
Approximate percentage of work below 3 metres depth: | % |
Total: | 100% |
If you undertake any work below 3 metres depth, please provide details of the type of work and the percentage of your turnover this work represents: | |
Height Work |
Please confirm the maximum height you would work: | metres |
If any work is above 15 metres, please provide details: (e.g. type(s) of contract(s)/work undertaken, and percentage of turnover that this work represents) | |
Trading Experience |
How many years has your business been trading? | |
Number of years previous experience in this trade: (A minimum of 3 years previous experience is required if you have 0 years trading) |
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Health & Safety |
Do you have a written Health & Safety policy in force which is reviewed regularly and distributed to employees? | Yes No |
Do you carry out a full Health & Safety Risk Assessment at the contract site before commencing work? | Yes No |
Are written Method Statements prepared for each contract? | Yes No |
Is Health & Safety training given to employees and is the training recorded? | Yes No |
Do you supply and enforce use of Personal Protective Equipment (PPE) where required? | Yes No |
Do you ensure plant is maintained and in good order? | Yes No |
Hazardous Substances |
Do you or your employees work with asbestos, silica, explosives or any other substances hazardous to health? | Yes No |
If yes, please provide details: | |
Hazardous Activities |
Do you or your employees carry out any demolition work on buildings or structures? | Yes No |
Please confirm the percentage of demolition work: | |
Please provide details of demolition work: (i.e. type of demolition work carried out, method of demolition (e.g. hand demolition, machine demolition, etc.)) | |
Does any of your demolition work involve the use of explosives? | Yes No |
Claims 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: | | |
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| | Manual Principals | | Non-Manual / Clerical Principals |
Number of Proprietors/Partners/Co. Directors: | No. | | No. | |
Annual Wages of Proprietors/Partners/Co. Directors: | | | | |
Please confirm your annual payments to Bona-Fide Sub-Contractors (BFSC's): (BFSC's are sub-contractors who supply their own materials on site and hold their own insurance) | | |
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Employers' Liability (Compulsory by Law if you have direct employees or use labour only sub-contractors)
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Is Employers' Liability Cover Required? (£10M standard limit of indemnity) | | |
| | Manual Workers | | Non-Manual / Clerical Workers |
Number of Employees/Labour Only Sub-Contractors: (Do not include proprietors, partners or directors) | No. | | No. | |
Annual Wages of Own Employees: | | | | |
Annual Payments to Labour Only Sub-Contractors (if used): (LOSC's are sub-contractors who supply labour only and work under your supervision) | |
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Employers' Reference Number (optional) |
Employers' Reference Number (ERN) (if available): | (e.g. '123/AB12345' or 'Exempt') |
Annual Turnover |
Estimated Annual Turnover for next 12 months: | | |
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Contract Works (optional) |
Do you require cover for Contract Works? | Yes No
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Please state the maximum value of any one contract (£'s): | |
Please state the maximum length of any one contract (e.g. 6 months, etc.): | |
Own Plant (optional) |
Do you require cover for Own Plant? | Yes No
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Please confirm the total value of your Own Plant, Tools & Equipment required to be covered whilst working on site (£'s): | |
Please confirm the maximum value of any one item of your own plant (£'s): | |
Hired-In Plant (optional) |
Do you require cover for Hired-In Plant? | Yes No
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Please confirm annual charges/costs incurred (£'s): (e.g. £10,000 per annum) | per annum |
Please confirm the hired-in plant total sum insured for all items of hired-in plant (£'s): | |
Please confirm the maximum value of any one item of hired-in plant (£'s): | |
Employees' Tools (optional) |
Do you require cover for Employees' Tools? | Yes No
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Please confirm how much cover you require for your Employee's Tools (£'s): | |
Business Legal Expenses Cover (optional) |
Is Business Legal Expenses cover required? (£100,000 cover for legal disputes, employment disputes, tax investigations, etc.) | Yes No |
Legal Expenses Limit of Indemnity: | | |
Has the business and/or its directors been involved in any legal dispute, tax investigation or any other court or tribunal action in the last 5 years? | Yes No |
Please provide details of the dispute including dates: | |
Directors & Officers Cover (optional) |
Do you require Directors & Officers Cover? | Yes No
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Can you confirm that the company is domiciled in the UK; is privately held; has not raised any funds from external parties; has been in operation for more than 12 months; has its financial statements prepared by a qualified accountant, shows a profit and are not subject to any concerns by the auditors; derives at least 50% of all its turnover from clients within the UK and EU; has not acquired any companies which have increased its total assets by 50% or more; and has no mergers or acquisitions planned and has not had any claims made against it or its directors and is not aware of any circumstances that could give rise to such claim? | Yes No |
If no, details: | |
Limit of indemnity required? | | |
Additional Information
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Details of any additional information you wish to disclose or any other cover required: | | |
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: | | (dd/mm/yyyy) |
Current Annual Premium / Best Quotation: | | This may help us to get you a better quote |
Name of Current / Previous Insurer: | | e.g. Aviva, AXA, Allianz, QBE, RSA, Zurich, etc. |