Contractors Liability Insurance Quote Form
 

Please answer all questions- the more information we have the more competitive we can be.

(* mandatory field)

Proposer Details :
Name of Proposer: *
Ltd Company Name:  
Partners names
including full trading names (If not Limited):		 *
 

Contact Details:
Full Address:  
Post Code: *
Telephone Number:  
Mobile:  
Email Address: *
 
Business Description (for which insurance is required) :  
Nationality of Directors:  
Nationality of Employees:  
Date of company establishment:  
 

Cover Required:
 
Employer's Liability Cover Required:
(Limit of Indemnity £10m any one occurrence costs inclusive but £5m offshore)		  
Public Liability Cover Required:
(Standard Limit of £2m any one occurrence)		  
IRATA Member Y/N   Yes    No
IRATA Membership No  
Qualifications & Date obtained  
Next Assessment Date  
 

Claims:
Have there been any incidents in the last 5 years which have, or could have, given rise to any claims:

If Yes, please give details below:
Year:  
Description/Circumstances:  
Amount Paid:  
Amount Outstanding:  

General:
Do you undertake any Manual Work:  
If Yes, please provide details:  
 
Do you work in tunnels:  
If Yes, please provide details:  
 
Do you work in mines or in or for railways:  
If Yes, please provide details:  
 
Does your work involve Offshore Trips:  
If Yes, please provide details:  
Max no. of days in any one year:  
Describe fully the work undertaken:
 
Does this work take you outside UK?:  
If Yes, please provide details:  
 
Any working employees other than yourself:  
If Yes, provide numbers and work undertaken:  

Please provide details of annual wages paid to:
Principal:  
Others: Details:-
Level I/II:  
Level III :  
Others:  
 
Estimated Annual Turnover :  
 
Current Insurer name:  
Next Renewal date:  
 
Has any insurer ever declined your proposal, refused to renew or cancelled your policy or imposed special items?:  
 
if Yes, please give brief details:
 

Insurance period:
From:  
To:  
 
IMPORTANT
Declaration:

You are reminded of the need to disclose any facts which the Company would take into account in the assessment and acceptance of this proposal. If you have any doubts as to whether certain facts are relevant please contact us. Failure to disclose all relevant facts may invalidate your policy or may result in your policy not operating fully.

By submitting this form, I declare that the information given in this Proposal Form is to the best of my knowledge and belief correct and complete in every detail and will be the basis of the contract between me and the insurer.
 

(Services for UK residents and businesses only)