LIABILITY INSURANCE QUOTATION
PROPOSER
Name
T/as
Trade
Sole Trader
Partnership
Limited
Trading Since
Territory
UK Only
UK & ROI
ROI Only
LOCATION
Address
Postcode
CONTACT DETAILS
Tel
Fax
Mob
Email
Web
LIABILITY COVER LIMITS
Employers Liability
10 Mil Indemnity
Public/Prod Liability
1 Mil Indemnity
2 Mil Indemnity
5 Mil Indemnity
10 Mil Indemnity
WORK ATIVITIES
Your work and % split of each activity
INSURANCE HISTORY
Required Date
Current Insurer
Policy Number
Premium:
Current Broker
PROJECTIONS
Provide projections for the next 12 months
Number
Wages
Clerical/Office Staff
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
>20
Principal
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
>20
Direct (P.A.Y.E)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
>20
Labour Only Subs
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
>20
Workshop Machinists
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
>20
(Bona Fide)
Supply & Fix Subs
Turnover
WORK SPECIFICS
Height
0 m
<10m
<15m
<20m
>20m
Depth
0 m
<1m
<2m
<3m
<5m
>5m
Click If applicable to your work..
Use Of Heat
Scaffolding
Roofing
Towers
Bridges
Fly Overs
Quarrying
Tunnelling
Demolition
Railways
Chemicals
Asbestos
Airports
Steeples
On/Near Water
Explosives
Underpinning
Marine
Motorways
Piling
Design
Radiation
If selected give details in OTHER INFORMATION
CLAIMS RECORD
Tick if any claim in last 5 years
Give claim details, types, dates :
OTHER INFORMATION
Telephone 02870325999 for assistance