Combined Liability Form

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Name
E-mail
Phone Number

Area CodePhone Number
Mobile
Trading Name
Risk Address
Renewal Date

MonthDayYear
Present Insurers
Business Description
Details of Plant & Machinery/Equipment/Woodworking Machinery used:
Details of Experience:
*

Employers Liability
Number of Employees
*

Wage Roll split as follows:
Clerical
Non-Manual Working Directors
Manual Working Directors
Direct Employees
Labour Only Sub-Contractors
Bona Fide Sub-Contractors
Do you have a Safety Statement
*

Public/Products Liability
Limit of Indemnity
Turnover
*

Brief details of 3 Largest Contracts currently on hand or recently completed:
1 Description/Principal
1 Contract Price
1 Duration
1 Completion Date

MonthDayYear
2 Description/Principal
2 Contract Price
2 Duration
2 Completion Date

MonthDayYear
3 Description/Principal
3 Contract Price
3 Duration
3 Completion Date

MonthDayYear
Should be Empty:

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