General Questions

Note: Questions marker with a star (*) are mandatory

Insurance to commence one (Date): *
 

1. Company name: *
 

2. Full business description: *
 

3. Address of head office: *
(first line only)
 

Postcode: *  
   

4. Telephone Number: *
 

5. Date Business Established: *
 

6. Have you suffered any losses or claims during the last 5 years, which would have been covered by any of the insurances now proposed? * YesNo
  7. After enquiry is any Director, Partner, Principal or Employee aware of any claim, potential claim or circumstances or any facts that may affect the insurers consideration of this insurance? * YesNo
  8. Email: *