.:Oliver Wright Personal Financial Planning, New Ollerton:.

Date cover is required from:

Name		Trading as
Email address
Business address		Telephone
Period of time in business		Type of business/nature of work
Number of employees		Annual payroll
Estimated annual turnover
Do you or your employees work away from the premises?	Yes No
Nature of the work away
Number of employees involved in work away
Have you made any claims in the last 5 years?	Yes No
If so, please give details
Have you or your parner/director in connection with the business;
Been prosecuted under any safety legislation during the last 5 years?	Yes No
Had a proposal for insurance declined, renewal refused, increased premium imposed or cover terminated by any insurer?	Yes No
Been convicted of or charged with Arson, Violence or any offence involving dishonesty of any kind?	Yes No
If yes to any of the above, please supply details
Public liability cover level required
Employers liability cover required?	Yes No
Do you require tools cover?	Yes No
If yes, please state level required
Please add any further relevant points to ensure we provide an accurate quote for you.

'Authorised and regulated by the Financial Services Authority'
Firm reference no : 300051