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Directors Insurance Quote Form

For UK Customers Only

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

This form is designed for quotes for Directors and Officers Insurance only.

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

Personal/Company Details

Proposers 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:
(if different to the above)
Trading Status:
Postal Address:
Postcode:
Daytime Telephone Number:
Mobile Telephone Number:
E-Mail Address:

General Information

Description of your business activities:
(Please describe as fully as possible) help
Has the Company continuously
traded for at least 12 months?
Yes     No
Is the Company registered in the UK
(i.e. England, Wales, Scotland, Northern Ireland)?
Yes     No
Can you confirm that the Company is a private limited company (i.e. not publicly traded on any stock exchange), and there are no plans to trade the company's shares?Yes     No
Did the company report a positive
net worth at the last audited accounts?
Yes     No
If no, please provide details:
(i.e. are you working in accordance with your business plan?
When do you expect to be turning a profit and working with a positive net worth?)
Did the company have a net profit
at the last reported annual accounts?
Yes     No
If no, please provide details:
(i.e. are you working in accordance with your business plan?
When do you expect to be turning a profit?)
Are shares owned by anyone other than directors
of the Company or members of their families?
Yes     No
If yes, please provide details:
(include whether or not a financial institution
holds any shares and the precentage held)
How many shareholders does the Company have?
Are there any shareholders who
own more than 15% of the issued shares?
Yes     No
Please confirm the number of employees for the Company?Full-time:  
Part-time:
Has the business acquired any companies or
concerns since its last financial year end which have
increased its total assets by 50% or more?
Yes     No
Can you confirm that the business
has no mergers or acquisitions planned?
Yes     No
Can you confirm that the Company's annual report
and accounts are not overdue to Companies House:
Yes     No
Can you confirm that the Company's annual
financial statements have been prepared by a
qualified accountant and are less than 18 months old:
Yes     No
If no, please provide details of when they were last prepared:
Have you, or any other partner, director or trustee
ever been convicted, or charged but not tried, of
any criminal offence other than a motoring offence?
Yes     No
If yes, please provide details:
(e.g. details of offence(s), date of conviction(s),
details of fines / custodial sentence, etc.)
Have you, or any other partner, director or trustee
ever been declared bankrupt, insolvent, or been
subject of receivership or an administration order?
Yes     No
If yes, please provide details:
(e.g. date of bankruptcy/insolvency, amount, etc.)
Have you had any previous insurance
declined, cancelled or special terms applied?
Yes     No
If yes, please provide details:
Can you confirm that the Company's Directors, Officers or Managers, are NOT aware of any claim(s) that have been made in the past, or any circumstance(s) that could give rise to a claim being made in the future, against the Directors, Officers or Managers?Yes     No
If no, please provide details:
Can you confirm that no business or other activities under its past, present or planned future management or ownership involve any activities in Aviation, Banking, Telecommunications, Oil & Gas, Pharmaceuticals, Bio Tech, National or Local Government or Finance Sector:Yes     No
If no, please state type of location(s) and the
percentage of work spent at the location(s):
Does the Company have any
assets or any turnover in the USA?
Yes     No
If yes, please provide details:
Turnover
UK Turnover:
EU Turnover:
USA/Canada Turnover:
Rest of World Turnover:

Details Of Cover Required

Directors and Officers Cover
Directors & Officers limit of indemnity: help
Entity Cover (optional)
Is Entity Cover Required?Yes     No help
Employment Practice Liability (optional)
Is Employment Practice Liability Cover Required?Yes     No help
If yes, can you confirm that (i) you have a written grievance procedure in place; (ii) there is a contract of employment in place for all employees; (iii) you are not undergoing any downsizing or redundancy programme; (iv) you have not been the subject of any claims or employment tribunals:Yes     No
If no, please provide details:
Additional Information / Cover
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

Current Annual Premium / best quotation (£):
This may help us to get you a better quote
Current/Previous Insurer:
Inception/Renewal Date: (dd/mm/yyyy)
 
Request Quotation

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