Scaffolders Liability Insurance Quote Form

For UK Customers Only

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

This form is designed for scaffolders public liability insurance quotes. Cover can also be extended to include employers' liability insurance if you have your own direct employees or use labour only sub-contractors.

If you require any assistance to complete this form, please phone us on 01623 641386.

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:
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 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 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/cancelled cover or imposed any special terms?	Yes No
If yes, please provide details: (e.g. reason for any insurance refused/ cancelled/special terms imposed, and date when this occurred, etc.)
Have you, or any other partner or director ever had any County Court Judgements (CCJ's) / 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, date bankruptcy discharged or CCJ/IVA settled, circumstances of bankruptcy/insolvency/CCJ/IVA, 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)/prohibition order, circumstances of offence(s)/prohibition order, 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)
Work Activities
Description of your work activities: (e.g. scaffolding erector, etc. and a percentage split if you carry out more than one work activity)
Do you erect any spectator stands?	Yes No
If yes, what percentage of your turnover does this represent?	%
Do you undertake any propping or shoring work?	Yes No
If yes, please provide details of your most recent contract: (i.e. type of contract and value of contract)
Do you issue a handover certificate when the scaffolding is erected?	Yes No
Type of Premises Worked On / Locations (Must add up to 100%)
Please state the percentage of work carried out at the following premises / locations:
Private dwelling houses and flats?	%
Commercial buildings (e.g. shops, offices, etc.)?	%
Schools, leisure centres, hospitals, local authority buildings?	%
Industrial buildings (e.g. factories, industrial units, etc.)?	%
All other premises (state below if applicable)?	%
Total:	%

What percentage of the above work is on 'New Builds' (if applicable): (e.g. percentage work on new build houses, blocks of flats, etc., if applicable)	%
Is work carried out at any hazardous locations? (including, but not limited to; offshore installations, demolition sites, ministry of defence properties, railways, motorways, bridges, viaducts, power stations, nuclear installations, oil, gas or petro-chemical refineries, airports, quarries, tunnels, wells or mines, blast furnaces, pylons, watercraft, ships, boats, hovercraft, docks, harbours, piers, wharves, dams (incl. coffer dams), towers, steeples or spires, etc.)	Yes No
If yes, please state the type of locations and the percentage of work at these locations:
Is any work undertaken outside of the U.K.?	Yes No
If yes, please provide details: (i.e. area / country of work and percentage of time working outside UK)
Professional Services
Do you provide professional services for a fee such as advice/consultancy, design, testing, inspection and certification?	Yes No
Percentage of turnover relating to professional work:	%
Trading Experience
How many years has your business been trading?	year(s)
Number of years experience (if greater): (A minimum of 3 years previous experience is required if you have 0 years trading)	year(s)
Work At Height
Please state the maximum height worked:	metres
Please confirm the approx. percentage of time working at the following heights:
Up to 10 metres:	%
Up to 15 metres:	%
Up to 20 metres:	%
Over 20 metres:	%
Total:	100%
Do you or your employees use slings, cradles, bosuns chairs, abseiling equipment or similar?	Yes No
If yes, please provide details of equipment used and the percentage of time using this equipment:
Hazardous Materials
Do you work with asbestos, silica or any other materials hazardous to health?	Yes No
If yes, please provide details: (i.e. type of hazardous materials and percentage of your turnover for this type of work)
Trade Associations
Is the company a member of the NASC, CITB or any other trade association? (Discounts may be available if you are a member)	Yes No
If yes, please provide details of the trade association(s):
Health & Safety
Do you have a written Health & Safety policy in force?	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
Claims History
In relation to this business or any other previous business in which the proprietor or any partners or directors have traded, in this or any other name, has there been a claim under any of the cover(s) within the last 5 years?	Yes No
Claim 1.
Date of Loss:
Cause of Loss:
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:
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 Liability Cover Required

Public Liability
Public Liability limit of indemnity required:
		Manual Principals		Non-Manual/ Clerical Principals
Number of Proprietors/Partners/Company Directors:	No.		No.
Annual Wages of Proprietors/Partners/Company Directors:
Payment to Bona Fide Sub-Contractors (if applicable)
Annual payments to Bona Fide Sub-Contractors (if used): (Bona Fide Sub-Contractor's are sub-contractors who supply their own scaffolding on site and hold their own liability insurance)

Estimated Annual Turnover for forthcoming 12 months
Please confirm your estimated annual turnover:
If any part of the above turnover is for 'hire only' of the scaffolding, please state the percentage below:
Scaffolding 'hire only' percentage of turnover (if applicable):		%

Employers' Liability (Compulsory by Law if you have direct employees or labour only sub-contractors)
Is Employers' Liability required? (£10M standard limit of indemnity)		Yes No
		Manual Workers		Non-Manual/ Clerical Workers
Total number of employees/labour only sub-contractors: (Do not include proprietors, partners and directors)	No.		No.

Annual Wages of Employees at Own Premises (if applicable)
Annual wages of employees working at own premises:
Annual Wages of Employees Working Away on Site
Annual wages of employees working away on site erecting scaffolding above ground level: (Most wages would normally be under this category for employees erecting scaffolding)
Annual wages of employees working at ground level:
Annual wages of supervisors working at ground level:
Annual wages of drivers:
Annual payments to Labour Only Sub-Contractors (if used): (LOSC's are sub-contractors who supply only labour and not scaffolding on site)
Employers' Reference Number (Optional)
Employers' Reference Number (ERN) (if available):		(e.g. 123/AB12345 or 'Exempt')

Optional Covers

Legal Expenses Cover (Optional)
Is Contractors Legal Expenses cover required? (£100K 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:
Professional Indemnity Cover (Optional)
Is Professional Indemnity cover required? (Cover for any wrong advice, design, specification or certification)		Yes No
Professional Indemnity Limit of Indemnity:
Directors & Officers Cover (Optional)
Is Directors and Officers cover required? (Cover for any 'wrongful act' of a director or officer of the company)		Yes No
Please confirm the limit of indemnity required:

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

Date Cover is Required / Renewal Date:
Current Renewal Premium / Best Quote:		This may help us to get you a better quote
Name of Current / Previous Insurer:		e.g. Aviva, AXA, Focus, IIGL, Kerry London, Thistle, etc.

Request Quotation

Disclosure
Please ensure that all the information you have provided is correct and that you have answered all the questions accurately then press the Request Scaffolders Liability Quotation button and we will contact you shortly with a quotation.

Estimated Quote Time: 1 - 4 working days