Full quote

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Page 3 - History

Please complete as fully as possible and press "submit". Fields marked with an asterisk (*) are mandatory. Please enter "N/A" if a mandatory item is non-applicable.

3. History

Have you, your Directors, Partners or family members involved with the business or any other business ever:

i) had a proposal or insurance declined, cancelled or refused?*

Yes No
(If yes, please give details below)

ii) had any renewal refused?*

Yes No
(If yes, please give details below)

iii) had any special terms or conditions imposed?*

Yes No
(If yes, please give details below)

iv) been convicted or charged (but not yet tried) or been given an Official Police Caution, in respect of any criminal offence?*

Yes No
(If yes, please give details below)

v) been the subject of any County Court Judgements or Sheriff Court Decrees?*

Yes No
(If yes, please give details below)

vi) been declared bankrupt or insolvent or been disqualified from being a company director or been involved as owner Director or Partner with any company which went into receivership, administration or liquidation?*

Yes No
(If yes, please give details below)

vii) been involved in another company within 6 months before receivership/insolvency?*

Yes No
(If yes, please give details below)

viii) Prosecuted under the Health & Safety at Work act or had any health and safety prohibition notices imposed?*

Yes No
(If yes, please give details below)

ix) Any other material facts to disclose?*

Yes No
(If yes, please give details below)

Please provide details here

During the last 5 years have you sustained any loss or damage or incurred any liability; whether insured or not, in connection with any of the insurances for which cover is required?*

Yes No
(If yes, please give details below)

Date	Address where occurred	Cover type	£ paid	£ outstanding

Details of incident

Date	Address where occurred	Cover type	£ paid	£ outstanding

Details of incident

If further space is required, please enter details here: