Octagon House, 18 Nash Green, Hemel Hempstead, Herts. HP3 8AA        Phone :   01442 242 400
Liability
 
Business Name :
Contact Name (inc Title) :
Business Address :
Postcode :
Contact Number :
E-mail Address :
Renewal Date :   
Name of Existing Insurers :
Target Premium (£) :
BUSINESS ACTIVITIES
Date Business Established :   
Description of Business Activities :
Type of Premises Worked at: (i.e. Residential, Commercial &/or Industrial, please give examples) :
Maximum Height Worked at :
Maximum Depth Worked at :
Details of Any Heat Processes Undertaken :
PUBLIC LIABILITY
Limit of Indemnity :
Estimated Annual Turnover (£) :
Details of Any Work Outside of U.K. :
EMPLOYERS' LIABILITY
Limit of Indemnity :
Clerical/Managerial :
Est. Annual Wage Roll (£) :
Number of Clerical Only :
Manual Workers :
Est. Annual Wage Roll (£) :
Number of Manual Workers (inc. proprietor if manual worker) :
Est. Annual Payments Sub-Contractors :
Bona Fide (£) :
Labour Only (£) :
Max Number of Labour Only :
ADDITIONAL INFORMATION
Do You Have a Written Health & Safety Policy :
Have you had any claims in the past 5 years :

Do You Issue & Record Issue of Personal Protective Equipment? :

Please Give Details of ALL and ANY Claims/Losses You Have Suffered In The Past 5 Years: (please advise date(s), cost(s) and circumstances) :

Have You Ever Had an Insurance Policy Cancelled or Special Terms Imposed? :

Please Give Details of ALL and Any Additional Information/Comments :