Commercial & Construction Insurance Brokers Ltd
Acorn Business Park, Commercial Gate, Mansfield, Nottinghamshire, NG18 1EX
Telephone: 01623 633522 / Fax: 01623 420120
enquiries@ccibltd.co.uk
Authorised and regulated by the Financial Services Authority

Quotation Form

Email Address
Company Name
Address
Telephone Number
Facsimile Number
Contact Name
Brief Business Description
Current Insurer
Renewal Date
Number of Permenant Manual operatives - exclude clerical
(if not Ltd specify number of manual principals/partners)
Wages/Payments:

Turnover
Clerical/Managerial/Directors
Manual employees/Labour only subs
Bonafide sub contractors
Hired in plant charges
Cover Required:

Public Liability - Limit of indemnity
Employers Liability - limit of indemnity
Contract Works - limit per site
Own Plant & Tools - Sum insured
Hired in plant - Limit per item
Claims :

Have you had claims or losses in the past 5 years?
(If yes please confirm below including dates and costs)
Claim details
Any other relevant information
The answers to the above questions are treated as material facts. Any other facts known to you which are likely to affect acceptance or assessment of the risks proposed must be disclosed. Should you have any doubt about whether information is relevant it must be dislosed. A material fact is one which would influence insurers acceptance of your request for cover and the terms and conditions on which they are prepared to provide insurance cover.