|
|
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: | |
| Business Address: | |
| Postcode: | |
| Daytime 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 Details |
| 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 of conviction(s),
date(s) of conviction(s),
details of any fines and/or length of custodial sentence(s)) | |
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 of any insurance refused/
cancelled/special terms imposed, etc.) | |
Have you, or any other partner or director ever
had any County Court Judgements (CCJ's) /
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 |
Full description of your work activities: 
(Please describe as fully as possible including a
percentage split between each activity, if you carry
out more than one work activity.) | |
| Does your work involve muckaway? | Yes No |
| If yes, what percentage does this work represent? | |
Details of typical contracts carried out:
(e.g. foundations, paving, paths, etc.) | |
Do you undertake any piling, ground stabilisation,
dewatering, underpinning or basement excavation work? | Yes No |
If yes, please provide details:
(i.e. type of work and
percentage of turnover of this work) | |
Do you undertake any quarrying,
tunnelling, mining or sea defence work? | Yes No |
If yes, please provide details:
(i.e. type of work and
percentage of turnover of this work) | |
Does the business carry out construction, alteration,
repair, re-surfacing or excavation of any type of road? | Yes No |
If yes, please confirm type of roads worked on:
(e.g. A roads, B roads, motorways, etc.) | |
Does any of your work involve traffic management?
(e.g. temporary traffic lights, etc.) | Yes No |
If yes, please confirm type of traffic management used:
(e.g. temporary traffic lights, coning, etc.) | |
Is this work sub-contracted out
to a specialist Traffic Management Company? | Yes No (own employees) |
| Locations |
Is your home the base for your business or are you
operating from separate dedicated business premises? | Home Business Premises |
Is work away 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, watercraft/ships, docks, harbours, piers, towers, steeples, offshore installations, hospitals and other medical facilities.) | 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, percentage of time outside UK) | |
| Heat Use |
Do your activities involve the use of heat?
(e.g. blow lamps, blow torches, welding equipment, heat guns, etc.) | Yes No |
If yes, please state the type of heat used:
(e.g. blow lamps, blow torches, welding equipment, heat guns, etc.) | |
| Please confirm the percentage of time it is used: | |
| Details of Depth Work |
| Please confirm the maximum depth you would dig: | metre(s) |
| |
| Approximate percentage of work up to 1 metre depth: | % |
| Approximate percentage of work 1 to 3 metres depth: | % |
| Approximate percentage of work 3 to 5 metres depth: | % |
| Approximate percentage of work below 5-metres depth: | % |
| Total: | 100% |
If you undertake any work below 5 metres
depth, please provide details of the type of work
and the percentage of your turnover this work represents: | |
| Trading Experience |
| How many years has your business been trading? | year(s) |
Number of years previous experience in this trade:
(A minimum of 3 years previous experience is required if you have 0 years trading) | year(s) |
| 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 |
| Plant / Machinery |
Do you ensure plant and
machinery is maintained and in good order? | Yes No |
| Hazardous Substances / Materials |
| Do you or your employees work with asbestos, silica, explosives or any other substances hazardous to health? | Yes No |
| If yes, please provide details: | |
| Demolition Work |
Do you or your employees carry out
any demolition work on buildings or structures? | Yes No |
If yes, please provide details of demolition work:
(i.e. type of structures demolished) | |
What method(s) of demolition do you use:
(e.g. hand demolition, machinery, explosives, etc.) | |
| Please confirm the percentage demolition work: | |
| 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: | |
|
|
| Public/Product Liability |
| Public/Product Liability limit of indemnity: | | |
| | | Manual Principals | | Non-Manual/Managerial/
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 are sub-contractors who supply their own
materials on site and hold their own insurance) | | |
| Employers' Liability (Compulsory by Law if you have employees or use labour only sub-contractors)
|
Is Employers' Liability Cover Required?
(£10M standard limit of indemnity) | |
| | | Manual Employees | | Non-Manual/
Clerical Employees |
Number of Employees/Labour Only Sub-Contractors:
(Do not include proprietors, partners or directors) | No. | | No. | |
Annual Wages of Employees/L.O.S.C.'s:
(LOSC's are Labour Only Sub Contractors) | | | | |
| Turnover |
| Estimated Annual Turnover for next 12 months: | | |
| |
|
| |
| Contract Works (optional) |
| Do you require cover for Contract Works? | Yes No
|
| Please state the maximum value of any one contract: | |
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: | |
Please confirm the maximum value
of any one item of your own plant: | |
| Hired-In Plant (optional) |
| Do you require cover for Hired-In Plant? | Yes No
|
Please confirm annual charges/costs incurred:
(e.g. £15,000 per annum) |
per annum |
Please confirm the hired-in plant
total value/limit for all items of hired-in plant:
(e.g. £250,000) | |
Please confirm the maximum value
of any one item of hired-in plant: | |
| Employees' Tools (optional) |
| Do you require cover for Employees' Tools? | Yes No
|
Please confirm how much cover
you require for your Employee's Tools: | |
| Site Huts / Temporary Buildings (optional) |
| Do you require cover for Site Huts / Temporary Buildings? | Yes No
|
Please state how much cover you
require for site huts / temporary buildings: | |
| Directors & Officers Cover (optional) |
Is Directors and Officers cover required?
(Cover for any 'wrongful act' of a director of a limited company) | Yes No |
| Please confirm the limit of indemnity required: | | |
| 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: | |
| Legal Expenses Cover (optional) |
Is Commercial 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: | |
| 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. |
|
|
| 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. |
