Concrete Cutting / Diamond Drilling Public Liability Insurance Quote Form

Please insert your details below and one of our commercial advisers will contact you shortly with a liability insurance quotation.

This form is designed for quotes for Concrete Cutting / Diamond Drilling Public Liability and Employers Liability Insurance only.

If you have any problems with completing this form, please phone us on 01623 641 386 for assistance.

Personal/Company Details
Proposer's Full Name(s): (enter sole trader's name or all partner's names if a partnership)
Contact Name: (if different to proposer's name)
Limited Company Name: (if operating as a limited company)
Trading Name/Trading As: (if different to the above)
Trading Status:	- - - - - - Please Select - - - - - Sole Trader Partnership Limited Company Limited Liability Partnership Unincorporated Association
Business Address:
Postcode:
Telephone Number:
*E-Mail Address:
*Please note that your email address will only be used to provide you with your quote and not for any other marketing purposes.
General Information
Have you, or any other partner or director ever been convicted of or charged (but not yet tried) with any criminal offences other than a motoring offence?	Yes     No
If yes, please provide details: (e.g. type/reason for conviction(s), date(s) of conviction(s), details of any fines and/or community service (if applicable), length of custodial sentence(s) (if applicable),etc.)
Has any insurer ever refused renewal, declined or cancelled cover or imposed any special terms?	Yes     No
If yes, please provide details: (e.g. details/reason for any insurance refused/cancelled/special terms imposed, etc.)
Have you, or any other partner or director ever had any county court judgements / sheriff decrees / IVA's or been declared bankrupt, or involved in a company which has become insolvent or which has gone into liquidation, receivership or administration?	Yes     No
If yes, please provide details: (e.g. date(s) of bankruptcy/insolvency/CCJ/IVA, amount of bankruptcy/insolvency/CCJ/IVA, date bankruptcy discharged or CCJ/IVA settled, circumstances, etc.)	Please note we are unable to provide a quote if your bankruptcy is not discharged or your CCJ / IVA remains outstanding or unsettled.
Have you, or any other partner or director ever been prosecuted or served a prohibition order by the Health & Safety Executive?	Yes     No
If yes, please provide details: (e.g. date of prosecution(s), details of offence(s), etc.)
Have you, or any other partner or director ever been the subject of a recovery action from HM Customs and Excise or the Inland Revenue?	Yes     No
If yes, please provide details: (i.e. name of person or business subject to recovery action, date of recovery action, and reason for the recovery action)
Details of Business Activities
Description of your work activities: (Please describe as fully as possible including a percentage split between each activity, where you carry out more than one activity)
Does any of your work involve soil sampling, geological work, piling, tunnelling, or any other work an exposure to damage to underground services?	Yes     No
If yes, please provide details of the work: (e.g. type of work undertaken and length of these contracts)
Trade Associations / Accreditations
Are you a member of a trade assocation, and/or do you have any trade accreditations? (e.g. CITB, Constructionline, etc.)?	Yes     No
If yes, please provide details:
Premises / Locations Worked At (away from your own premises)
What percentage of your turnover is carried out at the following premises / locations:
(i) Private Dwelling Houses and Flats:	%
(ii) Commercial Premises (e.g. shops, offices, pubs, etc.):	%
(iii) Industrial Premises (e.g. industrial units, factories, etc.):	%
(iv) Other Premises/Locations (specify below if applicable) :	%
Total:	100%
Is work carried out at any hazardous locations? (These can include, but are not limited to; railways, motorways, bridges, viaducts, power stations, nuclear installations, oil, gas or petrochemical refineries, aircraft/airports/airside, quarries, mines, watercraft/ships, docks, harbours, piers, dams, towers, steeples and offshore installations.)	Yes     No
If yes, please state type of location(s) and the percentage of work spent at the location(s):
Is any work undertaken outside of the U.K.?	Yes     No
If yes, please provide details: (i.e. area / country worked at, type of contract(s) undertaken, and percentage of turnover this work represents)
Heat Use
Do your activities involve the use of heat? (e.g. angle grinders, blow lamps, welding equipment, heat guns, etc.)	Yes     No
If yes, please state the type of heat used: (e.g. angle grinders, blow lamps, welding equipment, heat guns, etc.)
Please confirm the percentage of time it is used:	0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%
Will heat work include the use of welding or flame cutting equipment?	Yes     No
Details of Depth Work
Please confirm the maximum depth you would work:	0 1 2 3 4 5 8 10+ metres
Approximate percentage of work up to 1 metre depth:	%
Approximate percentage of work 1 to 3 metres depth:	%
Approximate percentage of work below 3 metres depth:	%
Total:	100%
If you undertake any work below 3 metres depth, please provide details of the type of work and the percentage of your turnover this work represents:
Height Work
Please confirm the maximum height you would work:	0 5 8 10 12 15 20 30 40 50 60 70 80 90 100 100+ metres
If any work is above 15 metres, please provide details: (e.g. type(s) of contract(s)/work undertaken, and percentage of turnover that this work represents)
Trading Experience
How many years has your business been trading?	Please Select 0 Years 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years 27 Years 28 Years 29 Years 30 Years 30+ Years
Number of years previous experience in this trade: (A minimum of 3 years previous experience is required if you have 0 years trading)	Please Select 0 Years 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years 27 Years 28 Years 29 Years 30 Years 30+ Years
Health & Safety
Do you have a written Health & Safety policy in force which is reviewed regularly and distributed to employees?	Yes     No
Do you carry out a full Health & Safety Risk Assessment at the contract site before commencing work?	Yes     No
Are written Method Statements prepared for each contract?	Yes     No
Is Health & Safety training given to employees and is the training recorded?	Yes     No
Do you supply and enforce use of Personal Protective Equipment (PPE) where required?	Yes     No
Do you ensure plant is maintained and in good order?	Yes     No
Hazardous Substances
Do you or your employees work with asbestos, silica, explosives or any other substances hazardous to health?	Yes     No
If yes, please provide details:
Hazardous Activities
Do you or your employees carry out any demolition work on buildings or structures?	Yes     No
Please confirm the percentage of demolition work:	0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%
Please provide details of demolition work: (i.e. type of demolition work carried out, method of demolition (e.g. hand demolition, machine demolition, etc.))
Does any of your demolition work involve the use of explosives?	Yes     No
Claims Experience
Have you, or any other partner or director suffered any loss or had any claims made against you in the last 5 years?	Yes     No
If yes, please provide details:	Date of claim: Cost of claim:£ Details of claim: ---------------------------- Date of claim: Cost of claim:£ Details of claim: ---------------------------- Regrettably, if you have more than 2 claims, we will be unable to provide you with a quotation.

Liability Cover Required
Public/Product Liability
Public/Product Liability limit of indemnity:		£1 Million £2 Million £5 Million £10 Million Not Required
		Manual Principals		Non-Manual / Clerical Principals
Number of Proprietors/Partners/Co. Directors:	No.		No.
Annual Wages of Proprietors/Partners/Co. Directors:
Please confirm your annual payments to Bona-Fide Sub-Contractors (BFSC's): (BFSC's are sub-contractors who supply their own materials on site and hold their own insurance)
Employers' Liability (Compulsory by Law if you have direct employees or use labour only sub-contractors)
Is Employers' Liability Cover Required? (£10M standard limit of indemnity)		Please Select Yes No
		Manual Workers		Non-Manual / Clerical Workers
Number of Employees/Labour Only Sub-Contractors: (Do not include proprietors, partners or directors)	No.		No.
Annual Wages of Own Employees:
Annual Payments to Labour Only Sub-Contractors (if used): (LOSC's are sub-contractors who supply labour only and work under your supervision)
Employers' Reference Number (optional)
Employers' Reference Number (ERN) (if available):		(e.g. '123/AB12345' or 'Exempt')
Annual Turnover
Estimated Annual Turnover for next 12 months:
Additional Optional Covers
Contract Works (optional)
Do you require cover for Contract Works?		Yes     No
Please state the maximum value of any one contract (£'s):
Please state the maximum length of any one contract (e.g. 6 months, etc.):
Own Plant (optional)
Do you require cover for Own Plant?		Yes     No
Please confirm the total value of your Own Plant, Tools & Equipment required to be covered whilst working on site (£'s):
Please confirm the maximum value of any one item of your own plant (£'s):
Hired-In Plant (optional)
Do you require cover for Hired-In Plant?		Yes     No
Please confirm annual charges/costs incurred (£'s): (e.g. £10,000 per annum)		per annum
Please confirm the hired-in plant total sum insured for all items of hired-in plant (£'s):
Please confirm the maximum value of any one item of hired-in plant (£'s):
Employees' Tools (optional)
Do you require cover for Employees' Tools?		Yes     No
Please confirm how much cover you require for your Employee's Tools (£'s):
Business Legal Expenses Cover (optional)
Is Business Legal Expenses cover required? (£100,000 cover for legal disputes, employment disputes, tax investigations, etc.)		Yes     No
Legal Expenses Limit of Indemnity:
Has the business and/or its directors been involved in any legal dispute, tax investigation or any other court or tribunal action in the last 5 years?		Yes     No
Please provide details of the dispute including dates:
Directors & Officers Cover (optional)
Do you require Directors & Officers Cover?		Yes     No
Can you confirm that the company is domiciled in the UK; is privately held; has not raised any funds from external parties; has been in operation for more than 12 months; has its financial statements prepared by a qualified accountant, shows a profit and are not subject to any concerns by the auditors; derives at least 50% of all its turnover from clients within the UK and EU; has not acquired any companies which have increased its total assets by 50% or more; and has no mergers or acquisitions planned and has not had any claims made against it or its directors and is not aware of any circumstances that could give rise to such claim?		Yes     No
If no, details:
Limit of indemnity required?		£100,000 £250,000 £500,000 £1,000,000 £2,000,000 £5,000,000
Additional Information
Details of any additional information you wish to disclose or any other cover required:
You are required to make a fair presentation of the risk to insurers which means that you are required to disclose every material circumstance which you know or ought to know relating to the risk to be insured. Materially important information is any information that could influence an insurer's decision to accept your risk including the cost of your insurance. Failure to comply with the duty of fair presentation could mean that your policy is void or that insurers are not liable to pay all or part of your claim(s). By submitting this quotation you are confirming that there are no other material facts to disclose other than those shown above.
Details Of Current / Previous Policies
Cover Start Date / Renewal Date:		(dd/mm/yyyy)
Current Annual Premium / Best Quotation:		This may help us to get you a better quote
Name of Current / Previous Insurer:		e.g. Aviva, AXA, Allianz, QBE, RSA, Zurich, etc.

Request Quotation

Disclosure
Please ensure that all the information you have provided is correct, then press the 'Request Liability Quotation' button below and we will contact you shortly with a quotation.

Estimated Quote Time: 1 to 72 hours