Incorrect answers or failure to disclose all material facts may render the insurance inoperative. Material facts are those which would influence acceptance or assessment of the insurance risk. If you are in doubt, please disclose them or seek assistance from our insurance representative.
Full Name of Proposer(s) including all trading names, group companies and subsidiaries that are to be covered by the policy
Full Address of Premises to be Insured
Tel No
Fax No
Email Address
Please list names and dates of birth of all Directors/Partners
If you require Employers’ Liability cover, please supply your Employer PAYE Reference(s). (This information is required for us to provide Employers’ Liability cover. Where you have more than one PAYE Reference, please advise each one making it clear which company they apply to)
If you do not have a PAYE Reference, please confirm that you are exempt and give the reason.