Quotation Request

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EMAIL ADDRESS *

TELEPHONE *

MOBILE

INCEPTION DATE * dd/mm/yyyy

HOW DID YOU HEAR ABOUT US

PROPOSER DETAILS

TITLE

FULL NAME *

COMPANY NAME

TYPE OF COMPANY

PRIMARY TRADE

POSTCODE *

ADDRESS

GENERAL

PRESENT INSURER

If New Venture, please state experience

CLAIM DETAILS

Number of Losses / Claims in the last 5 years

Please provide details of all claims : Dates, Type of Claim and Loss Amount

SUMS INSURED

Buildings

Age of Building

Fixtures & Fittings

General Stock

Cigarettes & Tobacco

Alcoholic Spirits

Frozen Food / Deterioration of Stock

Electronic Business Equipment

Business Interruption

Fixed Glass/Signs/Sanitary Ware

Goods in Transit

Money in Transit/During Business Hours

Money in Approved Safe

Public & Products Liability

Employer's Liability

Additional Information

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