All fields marked * are compulsory

COMPANY NAME

Ltd Company Partnership Charity Sole Trader Choose company type

BROKER

FSA - Yes No

CONTACT NAME

ADDRESS

POSTCODE

TEL NO*

FAX NO

EMAIL ADDRESS*

ITC MEMBER

BUSINESS DESCRIPTION:

PERIOD OF COVER

HAZARDOUS ACTS:

CLAIMS:

ITEM

SUMS INSURED

Props/Sets/Cost/Instruments

£

Sound/Lighting/TV/Audio Equipment

£

Artists Property

£

Office Contents

£

(any other please list)

TOTAL

£

Public Liability - Indemnity limit £1,000,000 £2,000,000 £5,000,000 Please Select

Turnover £

Employers Liability

Average number of Employees

or

Wages £

Cash Limit

£500 or £

Personal Accident

£0 £10,000 limit £25,000 limit

Number of persons

Buildings

Sum insured £

including excluding subsidence

Business Interruption

£ Gross Profit

or

£ Increased Costs of Working

Where did you hear about us?*