Title	- Choose - Mr Mrs Miss Dr
Name
Company Name
No & Street
Address 2
Town
County
Postcode
Email Address		quotes are sent by email
Telephone Number					Mobile Number
Business Status				Please Choose Sole Trader Partnership Limited Company Plc	Date Cover Required from
How long have you been in business?										New Start One Year Two Years Three Years Four Years Five Years Six Years Seven Years Eight Years Nine Years Ten Years+
How many years experience do you have in this trade or business?										New Start One Year Two Years Three Years Four Years Five Years Six Years Seven Years Eight Years Nine Years Ten Years+
Do you operate your business from your home?							Yes No
Annual Turnover
Main Occupation	-Please Select- Blast Cleaning Contractor Shot and Bead Blasting Contractor Sand Blasting Contractors Descaling Services Other describe below						100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50%
Other Occupation	for which cover is required and does not form part of overall contracts undertaken under the "Main Occupation" option.						0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
Percentage of Work Away Involving Application of Heat.							0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%
Do you undertake work on commercial/industrial premises excluding shops and offices?							No Yes
Maximum Height Worked at							metres
Public Product and Employers Liability
Clerical Staff Numbers			Clerical Wages			Manual Staff Numbers			Manual Wages
Principals Directors
Direct Employees
Labour Only Sub Contractors
Bonafide Sub Contractors
Cover levels	Public and Products Liability				€2,600,000 €6,500,000
Employers Liability required?					€13M		No Yes
Claims / Loss Experience	Please give details of all losses whether insured or otherwise that have occurred in the last 3 years. If "none" state none						None
Any other comments that you feel may help our understanding of the business or that you feel may influence an underwriters opinion of the risk. Include details of any chemicals or processes that have been identified in any risk assessment undertaken.
Please note that an quotations will be subject to any appropriate health and safety and risk assessments having been completed and appropriate action having been taken.