Public / Employers Liability Insurance Quote Form

For UK Customers Only

Please enter your details below and one of our advisers will contact you shortly with a liability insurance quotation.

This form is designed for quotes for Public Liability / Employers Liability Insurance only.

Personal/Company Details
Proposers Name(s): (incl. all partners names if partnership)
Limited Company Name: (if applicable)
Trading Name:
Trading Status:	- - - - - - Please Select - - - - - Sole Trader Partnership Limited Company Limited Liability Partnership Unincorporated Association
Occupation/Trade:
Postal Address:
Postcode:
Daytime Telephone Number:
Mobile Telephone Number:
E-Mail Address:
General Information
Have you, or any other partner or director ever been convicted of any offences, been declared bankrupt/ insolvent or had any insurance refused or cancelled?	Yes     No
If yes, please provide details: (e.g. type of incident, date(s), amounts of bankruptcy, fines, custodial sentence, etc.)
Description of your business activities: (Please describe as fully as possible)
Is your home the base for your business or are you operating from separate dedicated business premises?	- - Please Select - - Home Business Premises
Is work carried out at any hazardous locations?	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)
Do your activities involve the use of heat?	Yes     No
If yes, please state the type of heat used (e.g. blowlamp) and how frequently it is used:	Type Used: Frequency:
Please confirm the maximum height you would work or depth you would dig (if applicable):	Max. Height: Max. Depth:
Trading Experience
How many years has your business been trading?	Please Select 0 Years 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years 27 Years 28 Years 29 Years 30 Years 30+ Years
Number of years experience (if different)	Please Select 0 Years 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years 27 Years 28 Years 29 Years 30 Years 30+ Years
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:	Date of claim: Cost of claim:£ Details of claim: ---------------------------- Date of claim: Cost of claim:£ Details of claim: ---------------------------- Regrettably, if you have more than 2 claims, we will be unable to provide you with a quotation.

Details Of Cover Required
Public/Product Liability
Public/Product Liability limit of indemnity:	£	1 Million 2 Million 5 Million Not Required
		Manual Principals		Non-Manual/Clerical Principals
Number of Proprietors/Partners/Co. Directors:	No.		No.
Annual Wages of Proprietors/Partners/Co. Directors:	£		£
Employers' Liability (Compulsory by Law if you employ staff)
Is Employers' Liability Cover Required?		Please Select Yes No
		Manual Employees		Non-Manual/Clerical Employees
Number of Employees: (Do not include proprietors, partners or directors)	No.		No.
Total Annual Wages of Employees:	£		£
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)	£
Turnover
Annual Turnover:	£
Tools Cover (Optional)
Tools Sum Insured:	£	(£2,500 max sum insured)
Additional Information
Any additional information / cover required:
Details Of Current / Previous Policies
Current Annual Premium:	£	This may help us to get you a better quote
Current/Previous Insurer:
Liability Renewal Date (if applicable):		(dd/mm/yyyy)

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Disclosure
Please ensure that all the information you have provided is correct, then press the Request Liability Quotation button and we will contact you shortly with a quotation.

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