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Full Name *

Full Address *

Contact Number *

Email *

Company/Business Name*

No. of Years in Current Business *:*

Estimated Turnover of Business*

Total Number of Employees (Including Directors)*

Current Insurer (If Any)*

Details of Plant, Equipment, Machinery*

Sum Insured (Value)*

Is The Item Registered? *

Please Select The Coverage Section/S Required From The Following*

Coverage Sections Required*

Have You (The Insured) Or Any Of Your Directors Ever Had Any Insurance Declined Or Cancelled?*

Have You (The Insured) Or Any Of Your Directors Ever Been Declared Bankrupt In The Last 10 Years?*

Have You (The Insured) Or Any Of Your Directors Had Any Criminal Convictions In The Last 10 Years?*

Have You Suffered Losses or Claims In Relation To Contractors' Plant, Machinery, Or Insurance in the Last 5 Years?*

Are Any Of Your Machines Used Or Expected To Be Used For Dry Hire Activities (Hired Out Without Operator)?*

Please solve: 5 × 4

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