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Employer's Liability Insurance Form
Acceptance Criteria
Please read the following assumptions carefully. Only click the yes box below you can agree with all assumptions.
You have a duty to make a fair presentation of the risk to us. You agree to an assumption or statement that is untrue or inaccurate in any way, the policy may not protect them in the event of a claim. The claim may be refused or the amount of the claim reduced.
Assumptions:
You must agree that their work does not involve any discharge of fumes, effluent or anything of a noxious nature.
You must agree that no proposer, director or partner of the Business, or its Subsidiary Companies, has either personally or in any business capacity:
• ever had any convictions or criminal offences which are not spent under the Rehabilitation of Offenders Act or has any prosecutions pending
• been prosecuted, served prohibition or served an improvement order und Health and Safety legislation in the last 6 years
• ever been declared bankrupt or insolvent or been the subject of bankruptcy proceedings or insolvency proceedings
• ever had a proposal refused or declined
• ever had an insurance cancelled or renewal refused
• ever had special terms imposed.
I Agree:
*
Yes
no
Personal Details
Please supply your contact details.
Title:
*
Please select
Mr
Mrs
Miss
Ms
Name:
*
First
Last
First and last names will suffice.
Postal Address:
*
Second Line Of Address:
Town/City:
*
County:
Post Code:
*
Phone Number:
*
Email Address:
*
Business Details
Business Name:
*
Business Description:
*
Please give a brief outline of your business.
Status:
*
Please select
Sole Trader
Partnership
Limited Company
How Long Has The Business Been Established:
*
Either supply year business started or how many years it's been running.
Projected Annual Turnover:
£
Pounds
Payroll:
*
£
Pounds
Employee Details
Number of Clerical Employees:
*
Please select
0
1
2
3
4
5
6
7
8
9
10
Number of Manual Employees:
*
Please select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Number of Manual Directors:
*
Please select
0
1
2
3
4
5
6
7
8
9
10
Number of Non Manual Directors:
*
Please select
0
1
2
3
4
5
6
7
8
9
10
