1. Contact Details

Full Name

Email

Phone Number

2. Company Details

Company Name

Please Provide the name of the company you wish to insure.

Company Address

Please Provide the full address of the company you wish to insure.

What Industry do you work in?

Have you been trading for at least 12 months?

Did you make a profit (that is, a net profit after tax) in the last 12 months?

Does your company have a positive Net Worth?

Are you a listed company?

Regulator Concerns

Has any regulatory body or auditor made any negative comments or raised any concerns in the last three years?

Overseas Subsidiaries

Does your company/organisation have any overseas subsidiaries?

Director Resignition / Replacement

Have any directors or trustees of the organisation resigned or been replaced in the last 12 months?

During the past 3 years:

Do you know of any:

Offer, acquisition or merger with another company?
Offer for more than 50% of your shares?
Planned or likely public offering of your securities within the next 12 months?
New subsidiaries started or bought since you last filed an annual report and accounts?

Directors & Officers Cover Limit

Corporate Legal liability Cover Limit

Employment Practices liability Cover Limit

Cyber Cover Limit

Policy Start Date

Who is your current Insurer (If applicable)

Target Premium Per-Year(£)