Combined
Liabilty Insurance - Quotation Request
Proposer's name
Contact name
E-mail address
Company or trading name
Business address
Postcode
Telephone No
Fax No (optional)
Description of trade or business
Are you an existing Rowett Insurance client?
Yes
No
Cover required
Employer's Liability
Is this cover required?
Yes
No
if yes please complete the section below, if no, please
click here
Estimated annual wages, salaries and other earnings
for the coming year
Description of all employees
Estimate (£)
Number of persons
Clerical and non manual work
Work overseas, offshore or on ships
Woodworking machinists
Work carried out at a height of more than 10 metres above
ground or floor level
For all other manual work please complete below and describe
duties
Duties
Estimate (£)
Number of persons
and for working Partners/Proprietors
Description of work
Estimate (£)
Number of persons
Has there been any incidents in the last five years which
have, or could have given rise to any claims under this
section?
Yes
No
if yes, please give full details in the box below including
dates, details of claims, any monies paid and outstanding
Public Liability
is this cover required?
Yes
No
if yes please complete the section below. If no please
click here
Indemnity limit required in respect of any one accident
£500,000
£1,000,000
over £1,000,000
if over £1M show limit req'd
About Wages
(state estimated annual payments of wages, salaries
and other earnings)
Estimate (£)
Number of persons
Work at own premises
Work undertaken away from your own premises
Please describe the nature of any such work,
if none, state 'none'
Do you engage in work at high risk premises involving the
use of heat?
Yes
No
work at high risk premises not involving the use of heat?
Yes
No
work at non high risk premises involving the use of heat?
Yes
No
work at non high risk premises not involving the use of
heat?
Yes
No
Products
Liability
is this cover required?
Yes
No
if 'no' please click here , if 'yes'
please complete the following section
please select indemnity limit
£500,000
£1,000,000
over £1,000,000
if over £1M show limit req'd
What goods do you manufacture, sell, supply,
repair, test, service or process?
Public & Products Liability
Claims History
Have there been any incidents in the last five years which
have, or could have given rise to claims?
Yes
No
if 'yes' please detail below including dates, details and
any monies outstanding and paid as applicable
Renewal Date of present insurance
(if applicable)
Insurance required from
Preferred Payment Method
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Credit Card
Debit Card
Cheque
Direct Debit