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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: | |
Occupation/Trade: | |
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 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 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) | |
Trade Associations |
Are you a member of a relevant trade association for your industry? | Yes No |
If yes, please provide details of organisation and membership number: | |
Business Activities |
Description of your work activities: (Please describe as fully as possible including a percentage split between each activity, if you carry out more than one activity) | |
Do you activities involve paint spraying? | Yes No |
If yes, please confirm the percentage of time paint spraying: | % |
Work Locations |
What percentage of the turnover is carried out away from your premises at the following locations: |
(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 Locations (specify below if applicable)
| % |
Total: | 100% |
Is your home the base for your business or are you operating from separate dedicated business premises? | Home Business Premises |
Is work carried out at any hazardous locations? (e.g. 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, 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): | |
Is any work undertaken outside of the U.K.? | Yes No |
If yes, please provide details: (i.e. area, percentage of time outside UK) | |
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 Work |
Please confirm the maximum height you would work: | metres |
Do you or your employees use slings, cradles, bosuns chairs or abseiling equipment? | Yes No |
If yes, please provide details: (i.e. type of equipment and percentage of turnover using the equipment) | |
Trading Experience |
How many years has your business been trading? | year(s) |
Number of years previous experience in this trade: (A minimum of 3 years previous experience is required if you have 0 years trading) | year(s) |
Health & Safety |
Do you have an up to date Health & Safety Policy tailored to your activities? | 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 / job? | 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 where required? | Yes No |
Do you work with asbestos, silica, explosives or any other substances hazardous to health? | Yes No |
If yes, please provide details: | |
Claims Experience |
Have you, or any other partner or director had any claims or incidents 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 (if used): (BFSC's are sub-contractors who supply their own materials on site and hold their own insurance) | | |
Employers' Liability (Compulsory by Law if you employ direct employees or 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. | |
Total Annual Wages of Employees/LOSC's: (LOSC's are Labour Only Sub Contractors) | | | | |
Employers' Reference Number (optional) |
Employers' Reference Number (ERN) (if available): | | (e.g. 123/AB12345) |
Turnover |
Estimated annual turnover for next 12months: | | | | |
Tools Cover (Optional)
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Tools Sum Insured (if required): | | £500 to £10K maximum |
Legal Expenses Cover (Optional) |
Is Commercial 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: | |
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. |