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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:
(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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Description of your business activities: 
(Please describe as fully as possible) | |
Has the Company
continuously traded for at least 12 months? | Yes No |
Is the Company registered in the UK?
(i.e. England, Wales, Scotland, Northern Ireland) | Yes No |
| Can you confirm that the Company is a private limited company (i.e. not publicly traded on any stock exchange), and there are no plans to trade the company's shares? | Yes No |
Did the company report a positive
net worth at the last audited accounts? | Yes No |
If no, please provide details:
(i.e. are you working in accordance with your business plan?
When do you expect to be turning a profit and working with a positive net worth?) | |
Did the company have a net profit
at the last reported annual accounts? | Yes No |
If no, please provide details:
(i.e. are you working in accordance with your business plan?
When do you expect to be turning a profit?) | |
Are shares owned by anyone other than directors
of the Company or members of their families? | Yes No |
If yes, please provide details:
(include whether or not a financial institution
holds any shares and the precentage held) | |
| How many shareholders does the Company have? | |
Are there any shareholders who
own more than 15% of the issued shares? | Yes No |
| Please confirm the number of employees for the Company? | Full-time:
Part-time: |
| Has the business acquired any companies or concerns since its last financial year end which have increased its total assets by 50% or more? | Yes No |
Can you confirm that the business
has no mergers or acquisitions planned? | Yes No |
Can you confirm that the Company's annual report
and accounts are not overdue to Companies House: | Yes No |
Can you confirm that the Company's annual
financial statements have been prepared by a
qualified accountant and are less than 18 months old: | Yes No |
| If no, please provide details of when they were last prepared: | |
Have you, or any other partner, director or trustee
ever been convicted, or charged but not tried, of
any criminal offence other than a motoring offence? | Yes No |
If yes, please provide details:
(e.g. details of offence(s), date of conviction(s),
details of fines / custodial sentence, etc.) | |
Have you, or any other partner, director or trustee
ever been declared bankrupt, insolvent, or been
subject of receivership or an administration order? | Yes No |
If yes, please provide details:
(e.g. date of bankruptcy/insolvency, amount, etc.) | |
Have you had any previous insurance
declined, cancelled or special terms applied? | Yes No |
| If yes, please provide details: | |
| Can you confirm that the Company's Directors, Officers or Managers, are NOT aware of any claim(s) that have been made in the past, or any circumstance(s) that could give rise to a claim being made in the future, against the Directors, Officers or Managers? | Yes No |
| If no, please provide details: | |
| Can you confirm that no business or other activities under its past, present or planned future management or ownership involve any activities in Aviation, Banking, Telecommunications, Oil & Gas, Pharmaceuticals, Bio Tech, National or Local Government or Finance Sector: | Yes No |
If no, please state type of location(s) and the
percentage of work spent at the location(s): | |
Does the Company have
any assets or any turnover in the USA? | Yes No |
| If yes, please provide details: | |
| Turnover |
| UK Turnover: | |
| EU Turnover: | |
| USA/Canada Turnover: | |
| Rest of World Turnover: | |
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| Directors and Officers Cover |
| Directors & Officers limit of indemnity: | |
| Entity Cover (optional)
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| Is Entity Cover Required? | Yes No
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| Employment Practice Liability (optional)
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| Is Employment Practice Liability Cover Required? | Yes No
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| If yes, can you confirm that (i) you have a written grievance procedure in place; (ii) there is a contract of employment in place for all employees; (iii) you are not undergoing any downsizing or redundancy programme; (iv) you have not been the subject of any claims or employment tribunals: | Yes No |
| If no, please provide details: | |
| Additional Information / Cover |
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. Ace, Aviva, AXA, Allianz, Chubb, RSA, Zurich, etc. |
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