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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 applicable): | |
Trading Name: | |
Trading Status: | |
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. |
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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 (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 (£'s), date bankruptcy discharged / date 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), details of offence(s), etc.) | |
Business Activities |
Description of your work/cleaning activities: (Please describe as fully as possible) | |
Please state the percentage split of your work activities: |
Window Cleaning (ground level / pole reach & wash): | % |
Window Cleaning Up To 10 Metres (ladders, etc.): | % |
Window Cleaning Over 10 Metres: | % |
Any Other Work not mentioned above (please specify):
| % |
Total: | 100% |
What percentage of the turnover is carried out at the following locations: |
(i) Private Dwelling Houses and Flats? | % |
(ii) Commercial Buildings (e.g. shops, offices, pubs, etc.)? | % |
(iii) Industrial Buildings (e.g. industrial units, factories, etc.)? | % |
(iv) Other Locations (please specify):
| % |
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 and steeples.) | Yes No |
If yes, please state type of location(s) and the percentage of work spent at the location(s): | |
Is your home the base for your business or are you operating from separate dedicated business premises? | Home Business Premises |
Is any work undertaken outside of the U.K.? | Yes No |
If yes, please provide details: (i.e. locations and how frequently) | |
Height Work |
Please confirm the maximum height you would work: | metres |
Do you use any slings, bosuns chairs, harnesses or cradles? | Yes No |
If yes, please provide details: (i.e. type of equipment and how frequently used) | |
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) |
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: | |
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Public/Product Liability |
Public/Product Liability limit of indemnity: | | |
| | Manual Principals | | Non-Manual/ Clerical Principals |
Number of Proprietors/Partners/Co. Directors: | No. | | No. | |
Annual Wages of Proprietors/Partners/Co. Directors: | | | | |
Please state 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) |
Is Employers' Liability Cover Required? (£10M standard limit of indemnity) | | |
| | Manual Employees | | Non-Manual/ Clerical Employees |
Number of Employees: (Do not include proprietors, partners or directors) | No. | | No. | |
Total Annual Wages of Employees: | | | | |
Employers' Reference Number (optional) |
Employers' Reference Number (ERN) (if available): | (e.g. 123/AB12345 or 'Exempt') |
Turnover |
Estimated turnover for the next 12 months: (Please be as accurate as possible, as an over estimation will increase the premium to be quoted) | |
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Personal Accident (optional) |
Is Personal Accident cover required? | Yes No |
If yes, please confirm sum insured required: | |
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: | |
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. |