Proposer Details
Name of Insured *
Website
Address of Business
Date Established *
Type of Business
Please Select One
Ltd Co
Sole Trader
Partnership
Type of Trade *
Abseiling Contractors
Acoustic Engineers
Agricultural Contractors
Air Conditioning Engineers
Alarm Installers (Excluding heat other than soldering)
Architects / Surveyors / Consultants
Bathroom installer
Boiler services (Domestic)
Carpenters
Catering Contractors Exc mobile snack vendors
Cavity Wall Insulation
Ceiling Installers
Cleaners- excluding Window Cleaners
Coach Operators / drivers exc scheduled bus services
Computer Consultant
Computer Servicing
Concrete Repair & Drilling (Exc shuttering & formwork)
Construction Plant Repairers
Couriers
Damp-proofing Installer
Double Glazing Installers
Drain Cleaners
Ductwork installers
Electrical Contractors
Electronic Engineers Incl High-Tech
Exhibition Stand Erectors
Fencing Contractor
Fork Lift Truck Servicing
Gardeners Excl Landscaping
Grit Blasters
Groundworkers – 5 metre depth limit
Haulage Contractors / Drivers
Heating Contractor
High pressure water washing
Hydraulic Engineers
Insulation Contractor
IT Sales and repairs
Joiners
Kitchen Installers
Landscaping Contractors
Lift Engineers
Loft Insulation
Machinery Installation / Servicing Excl dismantling
Manufacture of Signs & Sign Erectors
Non-Destructive Testers
Office clerical only for contracting trades
Painter & Decorator
Pipe Fitters
Plastering, Pebble Dashing & Artexing
Playground Equipment Installers
Plumbers
Refrigeration Engineers
Removal contractors
Roller Shutter & Door Installation Excl automatic barrier
Roofing & Cladding
Safety Netting Contractors
Scaffolding Contractor
Shop Fitters
Shuttering / Formwork Contractors
Sprinkler Installer
Steel Reinforcing Rod Installers & concrete pourers
Stonemasons
Taxi Drivers
Telecommunication engineers
Tilers (Excluding Roofs)
Timber Treatment Contractors
Water Treatment Contractors
Window Cleaning
Wood working machinists
Other
Trade – Further details
Are you the Holding Broker *
Yes
No
Public Liability
Limit of Indemnity Required
£
Please Select One
£1m
£2m
£5m
£10m
Gross Turnover
(exc Payments to BFSC’s)
Earned within the United Kingdom or exported to each of the regions below,
during the last fully-completed financial year
UK
EU other than UK
USA / Canada
Any other territory
Bona Fide Subcontractor Payments (BFSC's)
( in addition to Gross turnover)
Employers Liability
Limit of Indemnity Required
£
Please Select One
£5m
£10m
EL Not Required
Does the proposer or any of their employees work
offshore, on watercraft, watercourses, dockside, breakwaters, seawalls, underground, in mines, quarries, on towers, steeples, chimney shafts, blast furnaces, dams, viaducts, bridges, tunnels, or with asbestos including asbestos cement roofing sheets
Yes
No
chemical works, gas works, refineries, power stations, nuclear plant, on aircraft, airside, on railways (other than non-trackside Green Zones) or on spectators stands
Yes
No
Wages Information
Clerical & Managerial (non Manual)
£
Manual Staff working on the premises of the Proposer only including Labour Only Sub Contractors
£
Staff working away from the premises of the Proposer including Labour Only Sub Contractors other than height work above 10 metres
£
Height work (above 10 metres) excluding cradles slings bosuns chairs and abseiling height work using including Labour Only Sub Contractors
£
Height work using cradles slings bosuns chairs, abseiling equipment including Labour Only Sub Contractors
£
Wood Working machinists (other than hand held tools) including Labour Only Sub Contractors
£
Does the Proposer work only within the UK and/or EU?
Yes
No
How many employees does the proposer have (excluding any purely clerical staff)?
Has the Proposer had any claim, incident or accident that might give rise to a claim within the last 5 years or since establishment of the business if less?
Yes
No
Is the Proposer aware of any employees complaining of, repetitive strain injury, vibration white finger, pain in their upper limbs, stress or respiritory problems?
Yes
No
Does the Proposer have a formal written health and safety policy and procedure in place?
Yes
No
Does the Proposer have a formal safety training plan for employees?
Yes
No
Does the Proposer issue Personal Protective Equipment to employees and retain a record of such?
Yes
No
Does the Proposer have a documented procedure for high risk activities such as work at height or with machinery?
Yes
No
Does the Proposer have and use a formal accident book?
Yes
No
Has any director or partner or principal ever been convicted of or charged (but not yet tried) with any criminal offence? Has the Proposer or any director or partner ever been Declared bankrupt or insolvent?
Yes
No
Has the Proposer been prosecuted under the Health and Safety at Work Act or similar legislation or had any disciplinary proceedings or investigation brought by any Regulatory Body (including the HSE) or been requested to attend an enquiry or tribunal?
Yes
No
Does the proposer carry out any work involving the use of heat away from their own premises (other than electric soldering irons or hot air guns)?
Yes
No
Broker Details
Broker / Agent Name
Contact Name *
E-mail *
Phone