Proposer details
Client's name:
Trading name:
Email address:
Business postcode:
Telephone:
About your business
Please describe what work you undertake and what goods are supplied, installed, erected, repaired, altered or treated by you:
Have you entered into any agreements assuming a liability for injury, illness, loss or damage for which you would not have been liable in the absence of such agreement?: Yes No
How do you ensure that any sub-contractors employed by you maintain adequate liability insurance:
Do you export directly, or to your knowledge, indirectly to the USA or Canada?:
Have you previously exported goods to the USA or Canada?: Yes No
Do your goods bear a permanent marking to identify the date of manufacture or distribution?: Yes No
Please give details of any facilities at your premises for loading or unloading vehicles:
Does the noise level at any place of work exceed the first action level (85db(A)) under the Noise at Work Regulations Act 1989? : Yes No
Have you or any principal in the business ever been prosecuted or received notice of intended prosecution, under the Health & Safety at Work Act 1974, Consumer Protection Act or any similar legislation?: Yes No
Operative cover
Please state which sections are to apply: Employers Liability Public Liability Products Liability
The standard indemnity limit for Employers Liability is £10,000,000 and Public / Products Liability is £1,000,000. If these limits are insufficient for your business, please indicate the indemnity required:
Optional extensions
If you would like us to consider the following extensions, please give us details of your requirements.
An indemnity for financial loss sustained by a customer or user of your goods, even if this is not accompanied by loss or physical damage to property: Yes No
If yes, please give details:
Employers liability cover in respect of persons visiting or working on any offshore rig or platform: Yes No
If yes, please give details:
Claims history
Do you have a claims history (within 5 years)?: Yes No
If you ticked yes, you must fill in the section below:
Date: D: M: Y:
Details of loss:
Amount:
