Please provide details of your claims within the last 5 years Date Incident details Amount paid Amount reserved

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1 Combined Liability Insurance Client name: Operating address: Company reg. number: Business description: Year business established: Current Insurer: Current Broker: Renewal date: Premium: Please provide the estimated figures ( GBP) for the next 12 months: Turnover (UK) Cost of materials included in above Turnover figure Percentage of turnover resulting from hire of equipment % Percentage of turnover resulting from work using heat % Public liability limit required 1 million / 2 million / 5 million Clerical / Admin / Non manual Directors Manual Directors Yard workers Drivers Manual workers (PAYE) Payments to Bonafide Subcontractors Payments to Labour Only Subcontractors No. of Employees Please provide details of your claims within the last 5 years Date Incident details Amount paid Amount reserved

2 In the event that an employee is injured at work, do you as a matter of policy: a) Provide rehabilitation / medical care to facilitate a return to work? Y N b) Continue to pay the employee s wages following the accident? Y N If yes, please provide details: Does the business: a) Have a Health and Safety policy which is available to your staff and visitors? Y N b) Is the Health and Safety policy the product of a process of consultation or approval from or by an Y N independent consultant? c) Take active steps to make available and known to staff / visitors its contents? Y N d) Ensure your Health and Safety policy is kept up to date? Y N e) Assess the adequacy of your Health and Safety processes and performance? Y N f) Review the circumstances of accidents at work to prevent a reoccurrence? Y N Does the business retain the following documentation: a) Health and Safety Risk Assessment records? Y N b) Instruction and Training records? Y N c) Method Statements / Work Instructions? Y N d) RIDDOR Forms? Y N e) Contract and sub-contract documentation? Y N f) Copies of certificates of insurance issued to CIS5 and CIS6 cardholders and all other bona fide Y N subcontractors? g) Register for the issue of Personal Protective Equipment? Y N Have all Risk Assessments issued been complied with? Y N Does the business or it s employees use, handle, transport or work in / any of the following: Radioactive substances or devices? % Asbestos? % Explosive substances? % Silica or material containing this substance? % Toxic or hazardous chemicals? % Any materials giving rise to dust or fumes? % Process involving a noise level in excess of 85db % Bridges, piers, docks or viaducts? % Towers, steeples, chimney shafts or blast furnaces? % Airports / airfields, aircraft or airside work? % Ships, boats, hovercraft, docks, wharves, railways? % Offshore installations, rigs or platforms? % Oil refineries, power stations, gas / chemical facilities? % Heights in excess of 15 meters? % Below ground level? % Cranes, slings, cradles or similar apparatus? % Are you a member of trade association? If yes please specify to which trade association you belong?

3 Contractors All Risks Insurance Do you require cover for this section? If yes please provide the following information: Current Insurer: Current Broker: Renewal date: Premium: Estimated annual Turnover Maximum length of any one contract Maximum value of any one contract Total value of own plant Maximum value any one item of own plant Maximum value of own scaffolding Maximum value of own hand tools Estimated annual hired in plant charges Maximum value any one item of hired in plant Estimated annual hired out plant charges If you hire out plant, do you do so under CPA terms? Employees tools Site huts and / or temporary buildings Months Please provide details of your claims within the last 5 years below: Date of incident Incident details Amount paid Amount reserved

4 Commercial Property Insurance Do you require cover for this section? If yes please provide the following information: Full address of property to be insured: Is the property fitted with an alarm system? Does the alarm system protect the entire property? Please confirm type of alarm signalling: Are the premises occupied solely by you? If no, please provide occupations of other tenants Bells Only / Central station / BT Redcare Please choose your sums insured: Buildings Tenants improvements Loss of rent (applicable only if rented out) 12 / 24 / 36 months Fixtures, fittings, machinery and other contents Hand tools Stock Stock of non-ferrous metals Office based computer equipment Office based laptops Computer equipment out of the office UK / EEC / Worldwide Money in transit to and from the bank Money on premises during business hours Money on premises out of safe out of hours Money in safe Money in transit to and from the bank Personal accident assault 10,000 / 100 per week Business interruption Gross profit sum insured Indemnity period Do you require any of the following optional extensions? Denial of access Murder, suicide and infectious diseases Specified supplier 12 / 24 / 36 months

5 Goods in transit Number of own vehicles Sum insured per vehicle Annual value of goods carried via own vehicle Sum insured per courier vehicle Annual value of goods carried via own vehicle Sum insured per postal sending Annual value of goods sent via post Geographical limit UK / EEC / Worldwide Please provide details of your claims within the last 5 years below: Date of incident Circumstances surrounding incident Amount paid Amount reserved

6 Motor Fleet Insurance Do you require cover for this section? If yes please provide the following information: Current Insurer: Current Broker: Renewal date: Premium: Current excess: Driving restriction: Approximately what percentage of regular drivers are aged: 20 or under: % 21 to 24: % 25 to 29: % 30 or over: % Do you do the following checks for all employees who may drive the vehicles? Take copies of new drivers licences? Take details of convictions? Check driving licences annually? Assess their driving ability? Please provide details of any serious motoring convictions incurred by any driver in the last 3 years Driver name Conviction code Date Sentence Alcohol level Do your vehicles travel outside the UK? If yes please estimate Number of days in EU Number of days outside EU If operating outside the EU please advise countries visited: Please complete the following details about your vehicles to be insured: Make Model Engine size Value Registration No.

7 Please advise if you have fitted any additional security devices to your vehicles Make Model Value Device fitted Please identify any claims in the last 5 years that have cost in excess of 5,000 and provide a description of the event and what steps have been taken to avoid a reoccurrence Year Details of incident Preventative measures taken Please provide us with a copy of your confirmed motor fleet claims experience for the last three years which you can obtain from your current broker. If you would prefer we can obtain this for you but we will require your written authorisation. Please speak with your contact at Martinez & Partners who will provide you with a template letter.

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