Name

Address

Postcode:

Telephone Number

Email Address

The premises (if different from above)

Insurance from

Insurance to

Are you registed to recover vat

Are the premises connected to

Residential address Commercial Premises Please Select

Are the premises situated in

Rural Area Residential Area Industrial Area Please Select

Please confirm the construction of the property

What security do you have on the premises

Have you suffered any loss or damage to your equipment in 5 years? (if yes please give full details)

Do you require hired in plant insurance?

Yes	No

If so how much do you spend on hiring plant?

What is the maximum value of one machine you hire

When is you liability insurance due for renewal?

Where are tools stored when not in use?

Is equipment left overnight at site?

Yes	No

Schedule of tools

I/we declare that to the best of my/our knowledge and belief the above statements are true and I/we have not withheld or concealed anything affecting the proposed insurance.

I/We declare that my/our machinery and plant (including mechanically propelled plant) is properly fenced, guarded and in good order and my/our premises are in a good state of repair.

I/We agree that this proposal and declaration shall be the basis of the contract between me/us and the company whose policy applicable to the insurance I/we also agree to accept.

I/We declare that if anything on this proposal was written by another person he/she acted as my/our agent for this purpose.

I confirm all of the above