Name: *

Address: *

Town: *

Postcode: *

Email:

Telephone::

Total value of equipment: New for old: £: *

Secondhand value: £: *

Maximum value of equipment on any one site: £: *

Value of Trailers: £:

Value of Mobile Toilets £::

Gross rental income: £:

Employees tools: £:

Turnover (for Public Liability): £:

Public Liability Sum Insured £:

Clerical Wages: £:

Manual Wages: £:

If you have sustained any losses in the past 5 years:

Please provide full details of date, circumstances and costs involved

From: *

To: *