GENERAL LIABILITY ENQUIRY FORM

PLEASE COMPLETE THE FORM BELOW ON 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

Clerical Wages

Director Manual Wages

All other staff manual wages

Woodworking Wages

Work away Wages

Heat Work away wages

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? *

Payments to BFSC

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