General
Proposer Name: (Please include trading and partners names if not a Limited Company)
Full Business Address including Postcode
Tel. No
Fax. No
Email Address
Business Description
Date Insurance to Commence
Date Established
How long have you been in business at this address?
Elsewhere?
Are you a member of any Trade Association?
Yes  No
If Yes please provide further details including membership number:
Please list the names, dates of birth and background of all the Company 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 Yes please provide further details including membership number:
How many persons do you employ
Employers Liability
Do you require this cover?
Yes  No
 
We will automatically provide you with a limit of £10,000,000
If an increased limit is required please indicate
£
Public/Products Liability
a) Please indicate limit of indemnity required
     or Other limit (please state amount)
£
b) Do you manufacture or supply 'own branded' cleaning consumables or      equipment?
Yes  No
     If 'yes' please provide details:
c) What is your estimated turnover for the supply of consumables?
£