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:*