AT Bell Insurance Brokers

If you would like to receive a quotation for Indemnity/Liability Insurance please complete this form as completely as possible. We aim to reply to all enquiries as soon as possible.

Your name:
Organisation:
Your address:
Postcode:
Phone number:
Fax:
Email:
Type of Liability:
Geographical limits:	UK ONLY
Public liability/indemnity:
Type of work :
Employers liability (standard indemnity £10 Million):	Number of paid staff - Number of voluntary staff -
Is there any manual work?:	Yes No If so what?
Do you have personnel working away from the premises in the UK?	Yes No If yes state duties
Clerical wages:	£
Manual wages:	£
Total wages:	£
Total annual income:	£
Present Insurer:
Renewal Date:
Premium:
Have you made a claim in the last 5 years?	Yes No
If 'Yes' please advise brief details:

AT Bell Insurance Brokers Ltd.
40 Croydon Road, West Wickham,
Kent BR4 9HT

Tel: 020 8462 0769
Fax: 020 8462 0773
E-mail: insure@atbell.co.uk