Name of Company      

Address of Company

Post Code                     

Nature of business     Sole Trader Partnership Limited Company Other      

Trade or Occupation 

Public Liability
Indemnity required      5 million 2 million 1 million

Number of Partners, Principals or Directors 
not engaged in manual work

Number of Partners, Principals or Directors 
engaged in manual work

Number of manual worker employees             
(including sub contractors) 
excluding Partners, Principals or Directors                               

Number of clerical employees                             
excluding Partners, Principals or Directors  

Additional cover required:            Employer's Liability        All Risks on Tools    
(Public Liability cover is mandatory)          Stock in Trade       

Personal Accident  click for details of cover available and use back button to return to your form
Number of staff requiring cover                    

Units of cover per person for death or total disablement benefit  None One Two Three Four
one unit =£5,000

Units of cover per person for temporary disablement benefit        None One Two Three Four
one unit =£50 per week

Buildings and/or Contents   click for details of cover available and use back button to return to your form

Buildings value        £50,000 £100,000 £200,000 Not required  

Buildings must be of standard construction i.e. brick, stone, concrete or other non-combustible material and roofed with slate, tiles, concrete, or other non-combustible material. They must be heated by low pressure hot water radiators, oil fired space heaters fed from a fuel tank in the open, gas appliances fed from public supply or electrical appliances.  They must be occupied by your business.                                                                                                  

Contents value         Not required £10,000 £20,000 £40,000 £50,000

Are all external doors fitted with 5 lever mortice locks and all accessible windows fitted with key operated locks?  

Is cover required for Accidental Damage? 

Contract Works   click for details of cover available and use back button to return to your form

Cover required?  Not required £100,000 £250,000 Higher limit - call me

Please confirm that the following statement is correct

I/We have experience in the type of work to which this request for a quotation relates.
I/We have not been involved in any incidents in the last five years which did give or could have given rise to a claim of a type which this insurance is intended to cover.
I/We do not use woodworking machinery, other than handheld portable power tools.
I/We do not use oxy-acetylene or similar equipment.
I/We do not work below 1 metre or above 22 metres height.
I/We do not come into contact with explosives, gases, toxic or corrosive chemicals, radioactive substances, asbestos or silica.
I/We do not undertake underpinning

I/We confirm that the above statements are true

Date from which you need cover to start (dd/mm/yyyy)    

Please enter below any further information that you think we should know  before preparing your quotation.

Tell us how to get in touch with you:

Please contact me as soon as possible regarding this matter.

Your initial quote, plus details of the extra cover you have requested will be sent to you by email or fax

The information you have provided  will only be used to allow us to prepare your quotation.  

We do not share our information with any organisation outside our own group other than for the purposes of placing and servicing your insurance. 

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Please check this box if you do not wish us to notify you of other products 

which we believe may be of interest.

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Copyright ©  [Harvington Services Ltd]. All rights reserved.
Revised: December 20, 2006 .