	Gothic Insurance Brokers Ltd Gothic House Station Rd, Old Harlow Essex CM17 0AP Tel – 01279 429024 Fax – 01279 433383 Email – enquiries@gothicinsurance.com

or call

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

Liability Insurance Quote

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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
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
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