Trading Name   

Contact Name    

Date established   

Renewal date    

Renewal Premium 

Current Insurer 

Claims in the last 5 years -Give details below:

 Telephone Number(s) 

email address 

Business Address

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SUMS INSURED

Machinery, Plant and all other contents      

Business Interruption                   

Stock of Non-Ferrous Metals             

Computer and other electronic equipment    

Buildings                           

Rent payable                        

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MONEY COVER

Money during business hours                    

Estimated annual cash carryings in the next 12 months 

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PUBLIC AND EMPLOYERS LIABILITY

Public Liability   1 million 2 million 3 million 5 million Please select    Employers Liability:  Required Not Required

............................................................................................................................................................

NUMBER OF EMPLOYEES

Number of Full or Part time Manual employees

Number of Full or Part time Clerical employees

Total Manual wageroll   Total Clerical Wageroll 

Annual Turnover 

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SECURITY OF PREMISES

Type of CCTV system fitted

 none    indoor only    outdoor only    indoor and outdoor

Type of alarm fitted

 none   bells only   Redcare or similar - maintained under contract

Other - Please give details      

Where is your stock/equipment stored

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GENERAL QUESTIONS

What percentage of your work is done away from the premises? 

Do you use heat away from the premises                  Yes     No

What is the maximum height you work at?                

Do you have a written Safety Procedures statement           Yes    No

Please describe the type of premises worked on including any high risk locations.

This form uses your Outlook Express e-mail to send the enquiry. If your PC is not set up for this and an error message appears, please hold down the left mouse button and highlight the whole form, then copy and paste the enquiry into your own email program and send to a.hogg@fmlinsurance.com