Life Science Proposal

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Third Choice

Company Details

Company Name(Required)

Please confirm your company entity

Please confirm the trade/profession that best describes your business

Please confirm your business description

Contact Name

First Last

Phone

Address

Street Address Address Line 2 ZIP / Postal Code Country

Further Information

Anticipated company annual turnover for the next 12 months

What % of your work is UK based?

Please enter a number from 0 to 100.

What % of your work is EU based?

Please enter a number from 0 to 100.

What % of your work is USA/North America based?

Please enter a number from 0 to 100.

What % of your work is Rest of The World based?

Please enter a number from 0 to 100.

In what jurisdiction are your contracts carried out?

Have you/your business had insurance or a proposal cancelled, withdrawn, declined or made subject to special terms?

Have you/directors of your business been declared bankrupt or become insolvent or made any voluntary arrangement with creditors or been subject to enforcement of a judgement debt either in a personal capacity or as a business?

Have you/directors of your business ever been convicted of or charged with any offence (including a civil penalty from the UK Border Agency), other than a motoring offence or conviction spent under the Rehabilitation of Offenders Act 1974? pt or become insolvent or made any voluntary arrangement with creditors or been subject to enforcement of a judgement debt either in a personal capacity or as a business? lled, withdrawn, declined or made subject to special terms?

Cover Options

What covers do you require?

Professional Indemnity

Public Liability

Employers Liability

Property (Buildings, Contents etc)

Legal Expenes

Professional Indemnity

Please confirm the year the company started trading

Please enter a number from 0 to 2100.

What is your largest contract in the last 3 years?

Do you use subcontractors or consultants to carry out your business activities?

What percentage of your turnover is paid away to sub-contractors or sub consultants?

Do you ensure that all of your sub-contractors and sub consultants have their own professional indemnity insurance?

Are you aware, after reasonable enquiry, of any shortcoming in your work that could lead to a claim against you. This could include a shortcoming which your client cannot reasonably put right; a complaint about your client's work or anything your client have supplied which cannot be immediately resolved; or an escalating level of complaint on a particular project?

Have you/your business had any previous losses, incidents or any claims which have given rise to a loss in the last 5 years?

What level of cover do you require?

£100,000

£250,000

£500,000

£1,000,000

£2,000,000

£5,000,000

£10,000,000

Other limit

Public Liability

What level of cover do you require?

£100,000

£250,000

£500,000

£1,000,000

£2,000,000

£5,000,000

£10,000,000

Other limit

Has any claim or loss, whether successful or not, ever occurred or been made against you or their predecessors in business, or any past or present partner, principal, director or employee in respect of public or products liability (whether previously insured or not) in the last 5 years

Please provide further information on claim(s)

Do you undertake or supervise any manual work other collection, delivery

Do you/your business undertake or supervise manual work in any of the following locations?

Railways docks or harbours, quarries, mines or collieries, chemical or petrochemical works, oil refineries, gas works or fuel storage facilities, power stations, nuclear plant, bridges, viaducts, tunnels, dams, chimney shafts, towers or steeples.

Do you undertake any work with asbestos or nuclear waste, products or services?

Do you sell, supply, manufacture, install, repair or service any products?

Employers Liability

Please confirm your anticipated wage roll for the next 12 months

Are you aware, after enquiry, of any potential disease or injury to an employee that may give rise to a claim?

Has any claim or loss, whether successful or not, ever occurred or been made against you or predecessors in your business, or any past or present partner, principal, director or employee in respect of employers' liability (whether previously insured or not) in the last 5 years?

Please provide further information on claim(s)

Property (Buildings, Contents etc) Insurance

Total buildings sum insured (If required)

Total contents sum insured (If required)

Total computers sum insured (If required)

Do you wish to cover portable business equipment?

Total sum insured for portable business equipment (EU Cover)

Total sum insured for portable business equipment (Worldwide Cover)

Do you wish to cover your business turnover?

Marketing Consent(Required)

Yes, I would like to receive email updates and marketing communications from All Med Pro.

No, I would not like to receive email updates and marketing communications from All Med Pro.

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