callbruce
0845 226 0909

Commercial Insurance Submission Form

Premium indication is based upon the information given but may be reviewed once the proposal form is completed in full. Therefore if upon receipt of the completed proposal form any answer fundamentally changes the nature of the risk, we reserve the right to either alter the premium or refuse to provide cover.

General Questions

   

Agency number:

Agency Name:

Agency contact number:

Contact with Agent or Client:

Client Name:

Client’s Address:




Client’s Postal Code:

Client’s Telephone No.:

Client’s Email address:

Brief Details of Risk:

Have there been any claims in the last 5 years?



If yes, please give details:

Current Insurer:

Policy Start Date:

Target Premium:

All material facts must be disclosed. Failure to do so may invalidate the policy. Should you require further information on a particular policy please contact callbruce immediately on 0845 226 0909. We reserve the right to contact your previous insurer to confirm your insurance history. The premium indication given from this submission form is valid for 30 days.

 

 

Members of B.I.B.A

Authorised and regulated by the Financial Services Authority
A UNITAS Broker