Insured Name:

Trading Name:

Address:

Contact Phone Number:

Email:

Occupation:

Full Business Description:

Do you manufacture Goods:
(If so please give full details)

Please indicate the Limit of Indemnity Required (Public/Products):

€2.6 million              
€6.5 million

No of Employees:
(including Directors if a Limited Co.)

Please state payments to Bona Fide Sub-contractors:
If not applicable please state so

Renewal Date:

Previous Insurers: