Liability Only  Insurance Quotation Form

Title	Mr Mrs Miss Ms Other	If Other Please Specify
First Name
Last Name
Business Name
Business Description
Address
Contact Number
Date of Birth
Public Liability	£1m £2m £5m
Do you require defective workmanship & service cover	Yes No
Is it just yourself to be named on the policy	Yes No
Name Date of Birth Company Status 1 2 3 4 5 6 7
What is the business status	Sole Trader Partnership Ltd Company
What is your estimated annual turnover
How long has the business been established
Will you be dealing solely with Private Cars & Lightweight Vehicles	Yes No
Please give details
Do you have any previous liability claims	Yes No
Previous Claim Claim Date Type of Claim Total Paid Out £ 1 2 3 4 5 6 7
Best Quote so Far £