Combined Liability Submission Form

Combined Liability Submission Form

Expert advice to ensure you are fully protected

 

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    Contact Details




    Please advise if proposer performs the following activities:

    Any Standalone roofing

    Work at a height in excess of 15 meters

    Work at a depth of more than 3 meters

    Employers Liability - €13,000,000:

    Is cover required?

    Occupation/Nature of Work undertaken

    No. of Employees

    Estimated Annual Wages/Payments

    Clerical

    Manual – Working Directors

    Manual – All other employees

    Labour Only Sub-contractors

    Do you have an up to date Safety Statement?

    Public Liability:

    Is Cover required?


    Limit of Liability Required:

    Contract Works:

    Is Cover required?





    Contract Details (Largest in Previous 12 Months)

    Total Contract Value


    Start Date
    End Date


    Start Date
    End Date


    Start Date
    End Date

    Claims

    To the best of your knowledge and belief have you or any other person(s) material to this risk been involved in any accident or loss or have any claims been made against you or them in the past five years?

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