Shops and takeaways


		325 High Street, Slough, SL1 1TX. Tel: 01753 537100. Fax: 01753 534100. Email us here

	COMBINED INSURANCE FORM
1. Full name
Address
Post Code
Email address
2. Do you require a quotation for:
i) Employers Liability Insurance?
The standard limit of indemnity for Employers Liability is £10,000,000 any one event. Do you require a quotation for the higher limit of £25,000,000?
ii) Public Liability Insurance?
iii) Products Liability Insurance?
Please select limit required for items ii and/or iii
3. Occupation (full description)
4.
a) Date of commencement of business
b) Proposer's/Director's Work Experience in this trade
c) Proposer's/Director's qualifications
d) Are you a member of a trade association?		If yes, state which:
		If yes, do you comply with the association's code of practice?
e) Do you have a standard contract between you and your client to which you comply? (if yes, please supply a copy)		What is the proportion of your work undertaken based on this contract?	%
f) Do you have a written health and safety policy?
5. Do you undertake design work for:
a) your own Contracts
b) Other work
6. Do you own any premises or have any representations or funds outside the United Kingdom?		If yes,please give full details:
7. Are all your employees United Kingdom Nationals?		If no, please state number and nationality of foreign employees:
8. Do you carry out any contracts involving any of the following?		If yes to any, please give full details:
a) work on Vessels, Dams, Reservations, Docks or Harbours?
b) Work in, on, or about Refineries or Oil, Gas, or Petrol Storage Depots?
c) Work in, on, or about Aircraft, Gases or Chemicals?
d) Use of Explosives, Acids, Gases or Chemicals?
e) Work away from your own premises requiring the use of
1. Flame Cutting or Welding Plant
2. Blow Torches/Blow Lamps
3. Hot Air Guns/Soldering Irons
f) Underground work
g) Underwater work
h) Cradle or abseiling work
i) Work at a depth exceeding three metres
j) Work at height
1. If yes, exceeding 15 metres, proportion	%
2. If yes, exceeding 25 metres, proportion	%
3. If yes, exceeding 50 metres, proportion	%
k) Tank cleaning
l) Demolition
m) Scaffolding
n) Structural Steel Erection
o) Fixed wood-working machinery (if yes, supply wage roll)
p) Radioactive substances or outher sources of ionising radiation
q) Asbestos or silica
r) Processes involving a noise level in excess of 90 decibels
s) Toxic, Hazardous or notifiable waste
t) Work on boats, ships or vessels
u) Work on offshore oil or gas installations
v) Work overseas
9. Do you require cover in respect of liability for injury or damage caused by:
a) Plant not licensed for road use (if so please attach Schedule)
b) i) Plant hired in		if so please state contract conditions and estimated annual hire charges
ii) Plant hired out
10. Are your premises in a good state of repair, and are your ways, plant machinery (at your own premises and all contract sites) properly fenced and guarded and otherwise in a good condition?
11. Have you ever been prosecuted under the Factories Act or other statue or regulations?
12. a) Please state name of present and previous insurers over the last three years
b) Has any insurer ever declined your proposal, refused to continue your policy, increased your premium, or imposed special terms?

13. Details of Payment and turnover Description	Estimated number of employees	Estimated annual payments employees and other persons
13. Details of Payment and turnover Description	Estimated number of employees	Work at your premises	Work away from your premises
Clerical, Commercial Traveller and Managerial Employees who do not engage in manual labour		£	£
All other Employees		£	£
Labour gangers, labour only Sub-Contractors and self-employed sub-contractors		£	£
Proposers own annual remuneration if working manually in business		£	£

Gross Annual Turnover	£
The terms "payments to employees" means the total wages, salaries and other earnings without any deduction in respect of national insurance, income tax, holiday with pay or contributory pensions.

14. Have you had any claims made against you in the last five years?

Employers Liability

Year	Total Wages	Settled Claims		Reserves for Outstanding Claims
Year	Total Wages	No.	Amount	No.	Amount




Total

Public/Products Liability

Year	Total Wages	Settled Claims		Reserves for Outstanding Claims
Year	Total Wages	No.	Amount	No.	Amount




Total

I/We the undersigned, this date desire to effect an insurance in terms of the policy/policies to be issued by underwriters and agree to render, at the end of each period of insurance, declarations in the form required by the Underwriters and to pay any additional premium due in excess of the amount estimated. I/We hereby declare that the above statements and particulars which I/we have read over and checked are true and that no information has been withheld which might increase the risk or influence acceptance by the underwriters; that I/we have not suppressed, mis-represented or mis-stated any material fact. That I/we have fairly estimated our wages and salaries expenditure, turnover, plant values and the like and that this proposal shall hold to be promissory and form the basis of the contract between me/us and the Underwriters.

Date:
Proposer:

The insurance will not be in force until the proposal has been accepted by the Underwriters.

Authorised and regulated by the Financial Services Authority

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