PER CAPITA ENQUIRY FORM

PLEASE COMPLETE THE FORM BELOW OR SEND YOUR PRESENTATION TO [email protected]

Name of Brokerage and/or Matrix Broker reference (eg AB1234) *

Broker Email *

Proposer Name *

Risk Address *

Business Description *

Years Trading at this address *

Please provide details of any claims history *

Limit of Indemnity Required *

Turnover *

Number of Employees (must be under 10 or under - if over 10 please see our wages and turnover product)

Does the insured or any of its employee use, handle, transport or work in/on any asbestos or silica or material containing these substances?

Does the business employ Bona Fide Subcontractors? *

Do you undertake any work above 10m?

Do the normal business activities involve the application of heat? *

Do you undertake any work at depth? *

Is any cover required for tools? *

If yes, please provide the value required & the single items limit required

Is cover required for tools left in unattended vehicles?

Legal Status of Business *

Target Premium

Does the proposer have any adverse financial history including but not limited to Liquidations, bankruptcy's, CCJ's, criminal convictions or pending prosecutions *

If answering yes to the question above please provide details

Has an insurer ever refused to renew or cancelled my/our policy or imposed special terms *

If answering yes to the question above please provide details

Any other information