COVER REQUIRED

PROPOSAL FOR PUBLIC LIABILITY INSURANCE
NAME OF PROPOSER
ADDRESS OF PROPOSER
example@example.com
TEL
EMAIL
example@example.com
OCCUPATION/BUSINESS
RISK COMPLETE THIS COLUMN WHERE COVER REQUIRED

General premises risk and explosion except liability for damage insurable by a Boiler Policy.
Description of premises (workshop, warehouse etc
Goods, hoists, cranes lifting tackles etc.
Estimate number of empolyees

	Description	Number	Motive Power	Whether over Public Street	Number of floors serve
1

c) Work away from your premises (including liability for fire and explosion except liability for injury or damage insurable by a Boiler Policy)
Where will the work be carried out
Who examines them for defects and how often
(d) No Of Employees of Sub Contractors
Nature of work sublet
1. Give full particulars and details of any machinery and electrical appliances used
(a) at your premises:
(b) Away from your premises:
2. Are all your premises and appliances in a sound state of repair
3.Have any person other than own employees occasion to use or come into contact with your lifts, hoists etc. Or anyother Machinery
4.How long have you been in business and what claims have been made on you during that period in respect of risks covered under this insurance?
Personal Injury No
Cost
Damage to property No
Cost
Number of years in business
5. (a) Are you at present insured?
(b) Have you ever proposed for insurance in respect of the said liabilities.
(b) Name of company
(c) has any proposal or renewal ever been declined, or withdrawn or changed an increased premium or subjected to Special restrictions?

LIMITED OF INDEMNITY

	For any on Accident	In any one year (Products & service)
1

Premium: Annual Premium
Wages
Turnover
I/We warrant that the above statements are true and I/We agree that this proposal and declaration shall be the basis of the contract between Me/Us and the company:
Date

MonthDayYear
Date
Signature

Clear
Agent
Should be Empty:

PROPOSAL FOR PUBLIC LIABILITY INSURANCE