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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: | |
Mobile 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 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) | |
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) | |
Percentage Split of Work |
What percentage of the turnover is split into the following activities (Must add up to 100%): |
(i) Percentage relating to Electrical Contracting work? | % |
(ii) Percentage relating to Heating, Ventilation, Air Conditioning and Refrigeration work? | % |
(iii) Percentage relating to All Other Work Activities? (please specify 'Other Work Activites' below if applicable)
| % |
Total: | 100% |
Do you carry out any 3 phase electrical work? | Yes No |
Does your work involve the connection of gas? | Yes No |
Are you involved in renewable energy including solar panel installation? | Yes No |
If yes, please provide details: (i.e. the type(s) of renewable energy installed and the percentage of your turnover for each type) | |
Type of Premises / Locations Worked At (away from your own premises) |
What percentage of the turnover is carried out at the following locations (Must add up to 100%): |
(i) Private Dwelling Houses and Flats? | % |
(ii) Commercial Buildings (e.g. shops, offices, pubs, etc.)? | % |
(iii) Industrial Buildings (e.g. industrial units, factories, etc.)? | % |
(iv) Other Premises / Locations? (specify other premises / locations below if applicable)
| % |
Total: | 100% |
Do you carry out any ventilation and air conditioning work for any commercial kitchens and restaurants? | Yes No |
If yes, please confirm the percentage of work this represents: | |
Please provide details of the type of kitchens/restaurants: (i.e. high street restaurant chains, fast food establishments, staff canteens, etc.) | |
Do you carry out any refrigeration work in abattoirs, cold stores, large-scale supermarkets or warehouse/storage facilities? | Yes No |
If yes, please confirm the percentage of work this represents: | |
Please provide details of the size and stature of chiller/refrigeration units worked upon in the premises: | |
Please provide details of the maximum total potential value in storage at any one of these premises: | |
Does the work involve any use of heat away for these contracts? | Yes No |
Please provide details of any backup systems, if applicable, which are installed if some or all of the units do fail: | |
Hazardous Locations |
Is work carried out at any hazardous locations? (These can include, but are not limited to; offshore installations, railways, motorways, bridges, viaducts, power stations, nuclear installations, oil, gas or petrochemical refineries, aircraft/airports/airside, quarries, mines, watercraft/ships, docks, harbours, piers, towers, steeples, hospitals and other medical facilities.) | Yes No |
If yes, please state type of location(s) and the percentage of work spent at the location(s): | |
Work Outside UK |
Is any work undertaken outside of the U.K.? | Yes No |
If yes, please provide details: (i.e. area / country of work, type of contracts carried out, and percentage of turnover this work represents) | |
Hazardous Substances |
Do you or your employees work with asbestos, silica, explosives or any other hazardous substances? | Yes No |
If yes, please provide details: (i.e. type of hazardous substances, and percentage of turnover this work represents) | |
Professional Services |
Do you provide professional services for a fee such as advice/consultancy, design, testing, inspection and certification? | Yes No |
Heat Use |
Do your activities involve the use of heat? (e.g. blow lamps, blow torches, welding equipment, heat guns, etc.) | Yes No |
If yes, please state the type of heat used: (e.g. blow lamps, blow torches, 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 |
Height / Depth Worked |
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) | |
Do you or your employees use slings, cradles or abseiling equipment? (cherry pickers and platforms are acceptable) | Yes No |
If yes, please provide details of equipment used and how frequently it is used: | |
Please confirm the maximum depth you would dig: | metres |
Trading Experience |
How many years has your business been trading? | year(s) |
Number of years experience (if different to years trading) | year(s)
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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 |
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: | | |
| | 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 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 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 |
No. of Employees/Labour Only Sub-Contractors: (Do not include proprietors, partners or directors) | No. | | No. | |
Annual Wages of Employees/Labour Only Sub-Contractors: | | | | |
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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Financial Loss Cover |
Is Financial Loss Cover required? | Yes No |
If yes, please state limit of indemnity required: | | |
Professional Indemnity Cover |
Is Professional Indemnity Cover required? | Yes No |
If yes, please state limit of indemnity required: | | |
Does more than 25% of your turnover relate to design, advice, surveying, or consultancy carried out for a fee? | Yes No |
Is any work undertaken outside of the European Economic Area? | Yes No |
Please provide details of any years relevant industry experience and qualifications: | |
Have you had any claims or incidents that could give rise to a claim in the last 5 years? | Yes No |
If yes, please provide details: (e.g. dates of claims, amount paid, circumstances leading to the claims, etc.) | |
Tools Cover |
Is Tools Cover required? | Yes   No |
Tools Sum Insured required: | | | | |
Business Legal Expenses Cover |
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 |
If yes, please provide details: | |
Directors & Officers Cover |
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: | | |
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, RSA, Zurich, etc. |