Contact Name  
Business Name  
Address  

 

  
Business Status   Postcode  
Telephone Number   Fax Number  
Email Address  
Business Description  
Please describe any goods manufactured, supplied, installed, erected, repaired, altered or treated by you.  
Date Business Established  
Business Website  
5 Year Claims

 
Date Details Paid/Outstanding
 
Risk Details
Has a Formal Risk Assessment Undertaken?  

Is there a Written Health and Safety Policy in force?

  
Is there a system for the inspection of all parts of the workplace on a regular basis in order to identify defects and hazards and to ensure any corrective actions is taken?  
Is there work involving use of heat away from the premises?  
Details
Percentage of Work Away from the premises involving the use of heat. %
Work involving the use of woodworking machinery %
Details
Maximum height/number of storeys worked at by any manual employees externally.
Details

Workers exposed to noise levels above 85db? 

  

Details

Employees exposed to chemicals which are known to be associated with conditions such as dermatitis, cancer or respiratory problems etc.?  
Details
Workers visit or work at Offshore installations  

Details

Visits or work on Ships, other than water-borne vessels and/or aircraft?  
Details
Public/Product Liability Limit of Indemnity
Employers Liability Limit of Indemnity €13M minimum
Description (please complete in all cases) £ Wage roll (at premises)  Wage roll (away from premises No of Employees
Clerical, commercial travelers and managerial employees who do not engage in manual labour
All other employees
Labour gangers, labour only sub-contractors and self-employed hired or borrowed persons
All other sub-contractors
Proposer’s own annual remuneration if working manually in the business
(Total payments must include overtime and board and lodging without deductions such as National Insurance, Income Tax etc.)
Turnover (or Gross Fees) UK Only
  EU and Europe
  ROW
  USA/Canada
Do you export directly or, to your knowledge, indirectly to USA or Canada?  
 
Do you export goods to any other countries?  
 
Do you import any goods?  
 
Do your goods bear a permanent marking to identify the date of manufacture or distribution?  
 
Do you undertake any design work on a fee only basis?  
 
General Questions
Have you, your Directors, Partners or family members involved with the business or any other business ever:
had a proposal or insurance declined cancelled or refused?  
Details  

had any renewal refused?

  

Details  
had any special terms or conditions imposed?  

Details  

been convicted or charged (but not yet tried) or been given an Official Police Caution, in respect of any criminal offence?

  
Details  

been the subject of any County Court Judgments or Sheriff Court Decrees?

  
Details  
been declared bankrupt or insolvent or been disqualified from being a company director or been involved as owner Director or Partner with any company which went into receivership, administration or liquidation?  
Details  
been involved in another company within 6 months before receivership/insolvency?  
Details  
Any other material facts to disclose?  
Details  
Please disclose any other facts that may be relevant, this will include information such as special equipment used, any certification or specialist training and any aspect of your business that may be outside what would normally be expected.