John Chadwick Insurance : Car Insurance, House Insurance and Commercial Insurance

Liability

Please take the time to fill out the form below:

Enter the names of all Proprietors, Partners, Directors:

Company Name (if applicable):

Trading Name:

Address:

Town:

County:

Postcode:

Telephone Number:

Mobile:

Email:

Business Status:

Primary Trade or Business:

Secondary Trade or Business:

If heat equipment is used, please select the type used:

Does your work involve the use of asbestos, chemicals or other substances which could be harmful to health?:

Do you dispose of fumes, effluent or other harmful waste?:

Please select the description of where the majority of the trade or business work is done:

Has the proposer, director or partner ever had a proposal refused or declined, or had an insurance cancelled, renewal refused or had special terms imposed?:

Does the proposer, partners or directors of the proposer have any convictions for any criminal offence involving dishonesty arson theft or wilful damage or any prosecutions pending?:

For any of the classes of insurance proposed, has the proprietor any partner or director suffered any loss or had any claim made against them whether insured or not in the last 5 years?:

Has any of the proprietors, partners or directors been declared bankrupt or insolvent or been the subject of bankruptcy proceedings?:

(if any of the above questions have been answered Yes, please enter details in comments below)

Please enter the number of working proprietors and partners:

Is cover for Employers Liability required?

(The temporary employees extension will only apply if 'YES' is entered to this question and at least one manual employee, for contracting trades or one clerical employee, for professional trades is entered)

Excluding Partners & Proprietors, please enter the number of working directors & employees at anyone time engaged solely in clerical work:

Excluding Partners & Proprietors, please enter the number of working directors & employees at anyone time engaged solely in manual work:

Is cover required for loss of or damage to portable tools and business equipment and property in transit?:

Do employees or labour only sub contractors use fixed woodworking machinery?:

Public liability limit:

Comments:

Security Code: