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Liability by Yutree

Quote Form

Date of submission

Insurance broker

Contact Info

Your Name

Your Email

Your Contact Phone No.

Basic Client Information

Company name including all trading names

Legal status

Address

Street Address Address Line 2 City County / State / Region Post Code

Full business description

Website

Year established

Employer Reference Number (ERN)

Has any proposer, director or partner of the business ever been declared bankrupt, insolvent, liquidated, or the subject of bankruptcy or liquidation proceedings, or any insolvency process?

Yes

Has any proposer, director or partner of the business ever had a CCJ or Scottish equivalent awarded against them?

Yes

Has any proposer, director or partner of the business suffered any convictions or criminal offences which are not spent under the Rehabilitation of Offenders Act or has any prosecutions pending?

Yes

Has any proposer, director or partner of the business ever had a renewal refused, an insurance policy cancelled, or had special terms imposed?

Yes

Has any proposer, director or partner of the business ever received any HSE enforcement notices, improvement notices, or prohibition notices?

Yes

Date Health & Safety was last updated

Is PPE issued and signed for?

Yes

Existing Cover

Current insurer

Number of years insured with current insurer

Renewal date

Last renewal premium

Target premium (if different from the above)

Cover Required

Employers' Liability

Yes

If yes, limit

Public/Products Liability

Yes

If yes, limit

Further information

Financial Estimates

Wageroll

Clerical/Managerial - premises

Clerical/Managerial - work away

Manual - Directors, Partners, Prinicpals - premises

Manual - Directors, Partners, Prinicpals - work away

Manual Employees - premises

Manual Employees - work away

Labour only subcontractors - premises

Labour only subcontractors - work away

Bona fide subcontractors - premises

Bona fide subcontractors - work away

Turnover

Turnover (if multi-trade please split turnover)

Further Information

Is any work carried out at high risk locations (airports / dockside / railways / power stations / nuclear sites / gas, oil or chemical industries etc.)?

Yes

Is any work carried out outside of the UK?

Yes

If yes to either of the above, please provide details

Heat work away

Yes

If yes, the percentage of heat work and the methods of heat work

Working at depth

Yes

If yes, percentage of work

Working at height

Yes

If yes, percentage of work

If you have answered yes to any of the questions in the above section, please provide further information below

Working at depth

Up to 1m

Up to 3m

Up to 5m

Over 5m (please also provide details)

Working at height

Up to 5m

Up to 10m

Up to 15m

Up to 20m

Over 20m (please provide details)

Claims

Please provide a full 5-year claims history.

Employers' Liability

Public/Products Liability

Additional Information

File upload

Drop files here or

Max. file size: 20 MB.

underwriting@yutree.com

01638 660 651

Yutree Underwriting

Yutree Insurance Ltd is authorised and regulated by the Financial Conduct Authority.

Registered office: 15 Kings Court, Newmarket, Suffolk, CB8 7SG

Registered in England No. 07718776

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