Gothic Insurance Brokers Ltd
Gothic House
Station Rd, Old Harlow
Essex CM17 0AP

Tel – 01279 429024
Fax – 01279 433383
Email – enquiries@gothicinsurance.com

Liability Insurance Quote

(with Criminal Convictions)

Where did you hear about us?

If other please specify:

If you take out Liability insurance with us you automatically qualify for a MINIMUM of £15 Discount on Commercial Vehicle Insurance

Firm Details
Company Status
Company /Trading Name
First Name(s)
Surname
Full Address
Postcode
Email Address
Telephone Number
About your convictions	(please list 1,2,3 in each section if you have more than 1 conviction)
Date of Offence
Date of Conviction
Type of Conviction (e.g GBH, Common Assault)
Sentence given by court (e.g. 5 years custodial or 100 hrs community service)
Sentence actually served (e.g. served 2 years then 3 months on tag)
Description of Incident (Please give as much information as possible)
Mitigating Circumstance (e.g. had drink problem at time now recovering alcoholic etc.)
Trade Description	List up to 3 trades from drop menus - if there are more than 3 trades OR you carry out any trades which are not listed please type them in box underneath
Trade 1
Trade 2
Trade 3
Additional/ unlisted Trades
Do you use Heat? If so please give details
Is there a maximum Height Limit? Is so please give details
Do you work solely on Private Dwellings, Shops, Offices, Public Houses and Hotels?

Cover Details
Public Liability Level of Indemnity
Do you require Employers Liability?
No. of Manual Principals, Partners/ Directors
No. of Manual employees or labour only sub-contractors
No. of Non-Manual Principals, Partners/ Directors
No. of Non-Manual employees
Do your payments to Bone Fide sub contractors exceed 25% of your annual turnover?
Do you require Tools cover?
If so what level of cover?
Do you require a quote for Contractors All Risk cover? (Covering Contract Works, Plant Hire etc.?	If so - we will contact you seperately for quotation.

Experience
How many full years have you been trading?
How many years experience do you have in the trade?

Claims History

Please give FULL details below of any claims against you or your company in the last FIVE years. (Please include date of claim, circumstances & any payments made or reserves held)

Additional Information
Please add any information you feel may affect the quotation.

How would you like to be contacted?

TELEPHONE: 01279 429024

Authorised & Regulated by the
Financial Service Authority
Firm Number: 300031

Gothic Insurance Brokers Ltd. is registered in England. Company Reg. Number 880423. Registered Office: Gothic House, Station Rd, Old Harlow, Essex CM17 0AP