Combined
Liabilty Insurance - Quotation Request
Proposer's name
Contact name
E-mail address
Company or trading name
Business address
Postcode
Telephone No
Fax No (optional)
Description of trade or business
Cover
required
Employer's Liability
if yes please complete the section below, if no, please click
here
Estimated annual wages, salaries and other earnings for the
coming year
Description of all employees
Estimate (£)
Number of persons
Clerical and non manual work
Work overseas, offshore or on ships
Woodworking machinists
Work carried out at a height of more than 10 metres above ground
or floor level
For all other manual work please complete below and describe
duties
Duties
Estimate (£)
Number of persons
and for working Partners/Proprietors
Description of work
Estimate (£)
Number of persons
Has there been any incidents in the last five years which have,
or could have given rise to any claims under this section?
if yes, please give full details in the box below including dates,
details of claims, any monies paid and outstanding
Public
Liability
is this cover required?
if yes please complete the section below. If no please click
here
Indemnity limit required in respect of any one accident
if over £1M show limit required
About Wages (state estimated annual payments of wages, salaries and other
earnings)
Estimate (£)
Number of persons
Work at own premises
Work undertaken away from your own premises
Please describe the nature of any such work, if none,
state 'none'
Do you engage in work at high risk premises involving the use
of heat?
work at high risk premises not involving the use of heat?
work at non high risk premises involving the use of heat?
work at non high risk premises not involving the use of heat?
Products
Liability
is this cover required?
if 'no' please click
here
please select indemnity limit
if over £1M show limit required
What goods do you manufacture, sell, supply, repair,
test, service or process?
Public & Products Liability Claims
History
Have there been any incidents in the last five years which have,
or could have given rise to claims?
if 'yes' please detail below including dates, details and any
monies outstanding and paid as applicable
Insurance required from
Preferred Payment Method
choose >>>
Credit Card
Debit Card
Cheque
Direct Debit
