1. Company Details
1.1. Please state the name and address of the principal Company for whom this insurance is required. Cover is also provided for the subsidiaries of the principal Company, but only if you include the data from all of these subsidiaries in your answers to all of the questions in this form.
 Insured Company
 
 Contact Name
 
 Address
 
 Telephone
 
 Fax
 
 Email Address
 
 Website
 
 
1.2. Please state when your company was established
 
1.3. i) How many directors and / or partners are there in the Company?
          
       ii) Please state below the details of all Partners / Directors.
NameDate of BirthYears in PositionYears ExperienceQualifications
  
  
  
  
       iii) Please state the number of employees
     Marketing / Sales / Business Development
     I.T. / Technical
     Other
 
1.4 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)
1.5 If you do not have a PAYE Reference, please confirm that you are exempt and give the reason.
 
1.6. Please state your fees received in respect of the following years:
  Currency
      Date of Financial Year End (dd/mm)
 
Last Complete
Financial Year
Estimate for Current
Financial Year
Estimate for Next
Financial Year
  (a) Domestic Turnover
  (b) USA Turnover
  (c) Other Territory Turnover
  Total Turnover
  Operating Profit / Loss