Public / Employers 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 Public Liability and/or 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)
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
Occupation/Trade:
Business Address:
Postcode:
Daytime Telephone Number:
Mobile 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 ever 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 (£'s), date discharged, or please confirm if still current, circumstances of bankruptcy/insolvency/CCJ/IVA, etc.)
Have you, or any other partner or director ever been prosecuted or served a prohibition order or improvement order by the Health & Safety Executive?	Yes     No
If yes, please provide details: (e.g. date of prosecution(s)/prohibition order, details of offence(s), details of any fines/action taken (if applicable), etc.)
Business Activities
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 activity, for example, 80% builder, 10% decorator, 10% plumber)
Is your home the base for your business or are you operating from separate dedicated business premises?	Home  Business Premises
Type of Premises/Locations Worked At
Please confirm the percentage of work carried out at the following locations:
Private dwelling houses and flats?	%
Commercial buildings (e.g. shops, offices, etc.)?	%
Industrial buildings (e.g. factories, units, etc.)?	%
All other premises/locations (state below if applicable)?	%
Total:	100%
Is work carried out at any hazardous locations? (These can include, but are not limited to; offshore installations, railways, motorways, bridges, viaducts, power stations, nuclear installations, oil, gas or petrochemical refineries, aircraft/airports/airside, quarries, mines, watercraft/ships, docks, harbours, piers, towers, steeples, 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 and percentage of time outside UK)
Hazardous Work Details
Do you or your employees work with asbestos, silica, explosives or any other hazardous substances?	Yes     No
If yes, please provide details:
Does any of your work involve the use of fixed woodworking machinery? (hand held power tools are acceptable)	Yes     No
If yes, please provide details: (i.e. No. of employees using the machinery and annual wages of the employees using the machinery)	No. of employees: Estimated wages:£
Do you or your employees use slings, cradles, bosuns chairs, abseiling equipment or tower cranes? (cherry pickers and mobile access platforms are acceptable)	Yes     No
If yes, please provide details of equipment used:
Do you provide professional services for a fee such as advice/consultancy, design, testing, inspection and certification?	Yes     No
Heat Use
Do your activities involve the use of heat? (e.g. blow lamps, blow torches, welding equipment, heat guns, etc.)	Yes     No
Please state the type(s) of heat used: (e.g. blow lamp, welding equipment, heat guns, etc.)
Please confirm the percentage of time it is used: (e.g. 5%)	0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%
Height / Depth Worked
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
Please confirm the maximum depth you would dig:	0 1 2 3 4 5 8 10+ metres
Trading Experience
How many years has your business been trading?	0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 30+ 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)	0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 30+ year(s)
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
Claim 1.
Date of Loss:
Cause of Loss:	- - - - - - - - Please Select - - - - - - - - Accidental Damage Aircraft and Other Aerial Devices Assault Employee Injury Escape of Beverages Escape of Oil Escape of Water Fire Fire (Arson) Flood Food and/or Drink Poisoning Fraud or Dishonesty of Staff Health and Safety Legislation Impact - Own Vehicle Impact - Third Party Legal Costs and Expenses Lightning Loss of Licence Malicious Damage Other Personal Injury Property Damage Pollution Professional Indemnity Replacement of Locks Robbery or Attempted Robbery Sprinkler Leakage Storm Subsidence, Ground Heave, Landslip Terrorism Theft or Attempted Theft Third Party Injury Third Party Property Damage Underground Services Damage
Circumstances of the Loss:
Total Cost of Loss (£'s): (including any amounts paid or outstanding)
Status of Claim:	Settled     Claim Still Pending
Do you wish to add another claim?	Yes     No
Claim 2.
Date of Loss:
Cause of Loss:	- - - - - - - - Please Select - - - - - - - - Accidental Damage Aircraft and Other Aerial Devices Assault Employee Injury Escape of Beverages Escape of Oil Escape of Water Fire Fire (Arson) Flood Food and/or Drink Poisoning Fraud or Dishonesty of Staff Health and Safety Legislation Impact - Own Vehicle Impact - Third Party Legal Costs and Expenses Lightning Loss of Licence Malicious Damage Other Personal Injury Property Damage Pollution Professional Indemnity Replacement of Locks Robbery or Attempted Robbery Sprinkler Leakage Storm Subsidence, Ground Heave, Landslip Terrorism Theft or Attempted Theft Third Party Injury Third Party Property Damage Underground Services Damage
Circumstances of the Loss:
Total Cost of Loss (£'s): (including any amounts paid or outstanding)
Status of Claim:	Settled     Claim Still Pending
Do you wish to add another claim?	Yes     No
Regrettably we will be unable to provide a quotation if you have had more than 2 claims.

Details of 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) (if used): (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)		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 Employees/Labour Only Sub-Contractors:
Employers' Reference Number (optional)
Employers' Reference Number (ERN) (if available):		(e.g. 123/AB12345)
Turnover
Estimated Annual Turnover for next 12 months:
Tools Cover (Optional)
Is Tools cover required?		Yes     No
Tools Sum Insured:		£500 to £10K maximum
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.
Details of Current / Previous Policies
Cover Start Date / Renewal Date:
Current Annual Premium / Best Quote:		This may help us to get you a better quote
Name of Current / Previous Insurer:		e.g. Aviva, AXA, Allianz, QBE, RSA, Zurich, etc.

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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