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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*:
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TYPE OF GOODS
CARRIED:
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DO YOU CARRY HAZARDOUS
GOODS?
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NO
YES
IF YES STATE %
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INCLUDING CLAIMS UNDER PREVIOUS TRADING NAMES HAVETHERE BEEN ANY
LIABILITY CLAIMS MADE AGAINST YOU IN THE PAST 5
YEARS?
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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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