Liability Insurance Quotation Form

Please complete as much of this form as possible as it will allow us to provide you with the most competitive quotation. Fields marked with an * are required.

Contact Details

Contact Name*

Company Name*

Company Status*

Number of Years Trading*

House / Building Number or Name*

Street Address*

Postal Town*


Post Code*

Telephone Number*

E-Maill Address*

Best method to contact you

Contact me by

Telephone E-Mail

If by Telephone please select

Best Days

Monday Tuesday Wednesday Thursday Friday Saturday

Best Time

Any Time 9am - Noon Noon - 3:00pm 3:00pm - 6-00pm

Business Infomation

Description of the Business / Trade*

Number of Years Experience*

Any process involving heat

Yes No

Height Limit

5M 10M 15M Over 15M

Depth Limit

1M 2M 3M 4M 5M Below 5M

Cover Required

Public Liability*

Employers Liability*

Number of Manual Principals*

Number of Manual Staff*

Number of Clerical Staff*

Annual Wageroll Manual £*

Annual Wageroll Clerical £*

Estimated Total Annual Turnover £

Current Insurance Details

Any claims in the last 5 years

Yes No

If Yes state approximate Dates, Causes and Costs

Renewal or Start Date*

Current Insurer*

What is your Renewal / Expiring premium?*

Please enter the phrase as it is shown in the box above.