Name or Company Name
Email Address
Postcode
Contact Phone Number
Business / Occupation
Unlisted Occupation  
Percentage of Work Involving Application of Heat.
Do you undertake work on commercial/industrial premises excluding shops and offices?
No of Manual Directors/Partners
Number of Manual Employees
Number of Clerical Partners
Number of Clerical Employees
Limit of Indemnity Required
Tools Cover Required per person
Provide details of any claims in the last three years.