Name
Address
Town		Postcode		Email Address
Telephone		Mobile

Business Description

Legal Status	Please Choose Sole Trader Partnership Limited Company	Date Business Established
Cover Required	Public Liability	£1,000,000 £2,000,000 £5,000,000
	Sales and Service Indemnity	Please Choose Not Required £1,000,000 £2,000,000
	Employers Liability	Please Choose Not Required £10,000,000
Location	Please Choose Motor Trade Premises Motor Trade Premises and Mobile Home Home and Mobile Mobile Only	Does your work involve the application of heat?	Please Choose Yes No

Description		Number	Annual Wages
Partners/Directors – manual
Partners/Directors - non-manual
Employed family members – manual
Employed family members – non-manual    Clerical/administrative
All others (including sales)
Annual Turnover
Have the Proposer(s), or any Partner(s), or Director(s) ever:
a) Had any proposal for insurance cancelled / declined to renew / require increased premium or special terms?		Please Choose Yes No
b) Been prosecuted or are any prosecutions pending under the Health and Safety at Work Act or any other statute or regulation?		Please Choose Yes No
c) Been convicted of, prosecuted for or are any prosecutions pending for any criminal offence (other than motoring convictions)?		Please Choose Yes No
Has the Proposer suffered a loss, claim or incident (which may give rise to a claim) at these premises, or any other premises, whether insured or not in the last 5 years?		Please Choose Yes No

If YES to any of the above, please give full details: