Where did you hear about us?

-- Please select -- Search Engine Online Directory Taxi Advert Existing Client Friend / Family William Martin School Other

If other please specify:

Disclosure Statement

Please ensure that all information you provide is correct and that you answer all questions accurately.

These details will form the basis of the insurance policy and any incorrect information could invalidate all or part of the insurance contract.

The proposer(s), or any partner, or director have never:-

a) been declared bankrupt or disqualified from being a company director

b) had any County Court Judgement(s) or Sheriff Court Decree(s)

c) had a company go into liquidation or become insolvent

d) been convicted or have any prosecutions pending or been given an official police caution, in respect of any criminal offence other than motoring offences

I confirm that I have read and agree that the above statement is true

Yes No

The Business

The Premises

Security

Please tick all the security measures that are in place at the premises.

External Doors - Yale lock

External Doors- 5 Lever Deadlock

Window Locks

Window Bars or Grills

Metal Roller Shutters

C.C.T.V. (Internal)

C.C.T.V. (External)

24 Hour Security

Covered Shopping Centre- Closed at night

Alarm System

Type of alarm -- Please select -- Bells Only Monitored- Central Station Private Dialler- Linked to Principal Redcare Redcare GSM

Cover Required

Do you want to extend the standard cover to include:

Additional Covers

Accidents / Convictions

Please give FULL details below of any claims by you or your company within the last five years

Please give dates, circumstances & full description of any claims

Additional Information

Please add any information you feel may affect the quotation.