Insurance application form
The purpose of this application form is for us to find out more about you. You must provide us with all information which may be
material to the cover you wish to purchase and which may influence our decision whether to insure you, what cover we offer you
or the premium we charge you.
How to complete this form
The individual who completes this application form should be a senior member of staff at the company and should ensure that they have checked
with other senior managers and colleagues responsible for arranging the insurance that the questions are answered accurately and as completely
as possible. Once completed, please return this form to your insurance broker.
Section 1: Company Details
Please state the name and address of the principal company for whom this insurance is required. Cover is also provided for the subsidiaries
of the principal company, but only if you include the data from all of these subsidiaries in your answers to all of the questions in this form.
Primary address (Address, State, ZIP, Country):
was established (MM/DD/YYYY):
Date of compa
ny financial year end (MM/DD/YYYY):
Please state your gross revenue in respect of the last complete financial year:
Please provide details for the primary contact for this insurance policy:
Contact name: Position:
Email address: Telephone number:
Section 2: Activities
Please describe below the products and services supplied by your business:
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