Public/Employers Liability Insurance Quotation

Quotation Request Form

Applicant's Name * First Last
Date of Birth * / DD / MM YYYY
Company/Trading Name *
Type of Business *
Number of Years Trading *
Address *
Street Address

Address Line 2

Town / City

County

Post Code

Country
Contact Telephone Number *

Please enter numbers only with no spaces
Email Address
Public Liability Limit *
Other Limit
Annual Turnover * £ . Pounds Pence
Additional Tool Cover If you require this please give full details and level of cover required.
Maximum Height (if applicable)
Claims History Please give dates and full details of previous claims.
Employers Liability Required? £10m *
If Employers Liability is required please complete the following.
Number of Employees
Wages for Manual Employees £ . Pounds Pence
Wages for Clerical Employees £ . Pounds Pence
Wages for other Employees (please give details below) £ . Pounds Pence
Please give detals of other employees
Additional Notes or Comments