Business Liability Insurance
Liability Insurance Quote
To help us provide you with out best possible quotation, please complete as much of the following liability insurance quotation form as you can.
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Title
Mr
Mrs
Miss
Ms
Dr
*
Name
*
Trading Name
*
Address
*
Postcode
*
Telephone
*
Email
Occupation/Trade
Number of Years Trading
Claims/Losses in the last five years
Public Liability
£1,000,000
£2,000,000
£5,000,000
Employers Liability
Required
Not Required
In order to calculate the premiums for the Liability sections we will require the following information
Number of principals / partners (manual work)
Number of principals / partners (non-manual work)
Number of directors (manual work)
Number of directors (non manual work)
Number of employees (manual work)
Number of employees (non manual work)
Number of Labour only Sub-contractors
Number of principals / employees working away from premises
Projected Annual Turnover
Projected Annual Wages (manual)
Projected Annual Wages (clerical)
Maximum External Height Worked
Meters
Maximum Internal Height Worked
Meters
Any heat application:-
None -
Blowlamps -
Welding -
Gas Cutting
Ever been declared bankrupt or insolvent?
Please Select
Yes
No
Been convicted of any criminal offence, which is not 'Spent'?
Please Select
Yes
No
Had any County Court Judgements entered in the last six years?
Please Select
Yes
No
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84 Church Street
Littleborough
Lancashire
OL15 8AU
Tel: 01706 378990
Fax: 01706 371417
Registered in England Number 939318
Authorised and regulated by
the Financial Services Authority
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© 2008 West Pennine Insurance Consultants LTD
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