Commercial Legal Expenses - Quotation Request

Proposer's name

E-mail address

Telephone No

Postal Address

Postcode

Trade or Business

General Questions

Description of work undertaken

Date of commencement of business activities

How much do you pay annually in wages before deductions?

How many people do you employ?

Have you ever held cover for this business or any of the covers applied for before?

Yes No

Has any insurer ever declined a proposal, refused renewal , terminated an insurance or imposed special terms

Yes No

if 'yes' please provide details

Has your business, you, or any of your partners or employees been involved in any legal dispute, action, prosecution, Customs and Excise dispute, Inland Revenue investigation/enquiry or DSS review during the last 5 years (excluding driving offences)?

Yes No

if 'yes' please provide details including date, outcome and the amount of legal costs and accountants' fees incurred (including employment awards)

To the best of your knowledge and belief are there any redundancies envisaged in your business within the next 12 months?

Yes No

if 'yes' please provide full details including the number of redundancies envisaged

In the last 3 years have you been taken over, merged with or taken over any other company, or to the best of your knowledge and belief is it likely that your company will atke over another firm within the next 12 months

Yes No

if 'yes' please provide full details in respect of the company(s) with whom you have (or intend to) merged with or taken over

Cover required from

to

Renewal date of present insurance (if applicable)