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*Please make sure you answer honestly, with accurate and up-to-date information. If you don't, your policy may be cancelled, and your insurer could reject your claim or decide not to pay it in full.* Capital Indemnity Ltd is Authorised and Regulated by the Financial Conduct Authority (936947) You can also contact us via email or by telephoning the office on 0203 488 7193 Our E-Mail address is: broker@capitalindemnity.co.uk
Contact Name:

First Name Last Name
Email:
Telephone Number:
Insured’s Name: (Please include trading and partners names if not a Limited Company)
Business Address:

Street Address 1

Street Address 2

City

Post Code:
Business Activities:
Date Company Established:
How many years experience do you have running a business in this industry?
If trading for less than 12 months please provide full details of relevant experience of the directors/principals), including the names of the previous companies worked for.
Do you require Employers' Liability cover? Employers' Liability Limitation is £10,000,000

Yes No
Do you require Public/Products Liability cover? Please choose one of the options below.

Public/Products Liability Limit £1,000,000 Public/Products Liability Limit £2,000,000 Public/Products Liability Limit £5,000,000
Do you have any employees? (including labour only subcontractors)

Yes No
If Yes, What is the insureds total number of staff (Employees and LOSC - Manual Work Away) helpers and/or volunteers?
What is the total number of Clerical personnel employed by the insured?
What is UK Turnover (including payments to Bonafide Sub Contractors)
What are the forecasted manual wage roll and work away figures for the the upcoming year?
What are the projected total wage roll clerical figures for the upcoming year?
*Height Work* Do you undertake any work above 10m? If Yes, What is maximum height in metres?
*Depth Work* Do you undertake any work at depth? If Yes, What is the greatest depth worked at in metres?
Do you undertake any work involving the use of heat? If Yes, Is the use of heat limited to the use of hot air guns, soldering irons, angle grinders and or handheld blow torches only?
Do you dispose of fumes, effluent or other harmful waste as part of your insured business activity?

Yes No
How many years has the business been trading continuously claim free (including incidents or accidents that could give rise to a claim) AND had continuous liability insurance? *
Has the Proposer or any Director or Partners declared bankrupt or insolvent, or are currently subject to any bankruptcy or insolvency proceedings?

Yes No
Have been subject to an investigation or prosecuted by the Health and Safety Executive and have any notices been issued?

Yes No
Has the Proposer or any Director or Partners ever been an Officer or a Director of an insolvent company?

Yes No
Has the Proposer, or any director or partner in the business, been disqualified under the Company Directors Disqualification Act 1986?

Yes No
Has the Proposer or any Director or Partners being convicted or charged with (but not yet tried), have any prosecution pending or given an official police caution in respect of any criminal offence or other offence other than a (road traffic) motoring offence or those considered spent by the Rehabilitation of Offenders Act?

Yes No
Has the Proposer or any Director or Partners had an insurance application refused or declined, an insurance cancelled or renewal refused, or any increased or special terms applied to any business insurance?

Yes No
Does the insured, or any director or partner in the business, have any outstanding County Court Judgement(s) or Sheriff Court Decree(s)?

Yes No
Has the Proposer or any Director or Partners been involved or associated with the management of any Company Partnership or Business which has ceased to trade following or as a result of the appointment of a receiver, liquidator, administrator or other insolvency Practitioner?

Yes No
Has the Proposer or any Director or Partners been involved or associated with the management of any Company Partnership or Business with an administrator liquidator or a supervisor or nominee under a voluntary arrangement or any compromise or arrangement with creditors whether formal or informal?

Yes No

Do you, or are you likely to undertake any work:

	Yes	No
a) Outside England, Scotland, Wales, the Channel Islands or the Isle of Man
b) Airside (except work inside terminal buildings)
c) Offshore
If YES, please supply further information in the "Additional information section."

Additional information!
DECLARATION

I/we declare that the above statements are true and I/we have not concealed any material fact that ought to be known or advised to the underwriters.

I/we agree that any variation in practices and/or safeguards and/or procedures will not be made without the knowledge and agreement of the underwriters.

I/we warrant that the above statements are true and agree that they shall be the basis of the proposed contract between the underwriters and yourself/yourselves and be incorporated therein.

I/we further agree to render at the end of each period of insurance a statement of all wages and/or salaries actually expended and/or turnover received and to pay any excess premium due.

It is further warranted that continued accuracy of the above statements, particulars and answers shall be conditions precedent to liability under the proposed insurances.
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