|
|
Fields marked *
are required
|
| Full name of Proposer :
|
|
(if not a Limited Company show full names of
all Principals/Partners and the Trading Name).
|
|
|
|
|
|
|
|
|
| Are you a Member of any Trade Association?
|
|
| If 'Yes' please provide full details: |
|
|
|
|
| Please give a full description
of your business activities including details of processes used,
equipment involved and any non-cleaning contracting activities you
may undertake: |
|
|
|
Do you undertake any work on or at chemical
works, gas works, oil refineries, power station, aircraft, airports,
ships, railway properties, offshore installations or bulk oil, petrol,
gas or chemical storage tanks or chambers?
|
|
| If YES, please provide details
: |
|
|
|
| Do you manufacture or supply "own
branded" cleaning consumables or equipment? |
|
| If YES, please provide details. |
|
|
|
| What is your estimated turnover for the
supply only of consumables? |
|
|
| In the past five years have any claims
been made upon you or notified (whether insured or not) in respect
of any of the insurances for which you are now proposing? |
|
| If YES, please provide the
following details: |
|
|
|
| Name of existing Brokers and/or Insurers |
|
| Renewal Date |
|
| Current Liability Premium |
|
|
|
|
| Principal, Partners, Wages for: |
|
|
|
|
| Payments to Bona-Fide Sub-Contractors
|
|
| Annual Turnover |
|
|
|
|
|
|
|
|
|
|
|
|