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All fields marked * are compulsory |
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NAME |
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POSTCODE |
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TELEPHONE NUMBER* |
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EMAIL ADDRESS* |
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WHOLESALE BROKER NAME & CONTACT NUMBER: |
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FULL BUSINESS DESCRIPTION: |
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COVER REQUIRED: (please tick)
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EMPLOYERS LIABILITY £10m
PUBLIC LIABILITY £2m
£5m
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NUMBER OF
VEHICLES UP TO 7sts (excluding driver)*: |
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NUMBER OF
VEHICLES 8sts AND ABOVE (excluding driver)*: |
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INCLUDING
CLAIMS UNDER PREVIOUS TRADING NAMES HAVE THERE BEEN ANY LIABILITY
CLAIMS MADE AGAINST YOU IN THE PAST 5 YEARS? |
NO
YES
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NAME OF
PREVIOUS INSURERS |
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EXPIRY DATE OF POLICY (DD/MM/YYYY) |
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RENEWAL DATE OF POLICY (DD/MM/YYYY) |
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WHERE DID YOU HEAR ABOUT US? * |
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