If you require any assistance in completing this form, or require further information, please call us on 0208 651 7420

For quick indications you need only complete down to Level of cover required.

* Please state the full legal title of the charity, group or organisation:

* Your Contact Name:

* Your Main Contact Number:

Your Evening Contact Number:

Your Mobile Contact Number:

* Your contact e-mail:

* First Line of address of charity, group or organisation:

* Post code of charity, group or organisation:

* How many years have you been established?:

On what date do you require the insurance to start?

*Annual Gross Income shown in most recent financial statements
*Annual wage roll for the charity - (if none state £0)
Level of cover required.  We can readily provide cover from £100000 to £5,000,000. You can select multiple limits by pressing the CTRL key.
Do you require fidelity guarantee insurance? ( Loss of money or other property arising from the dishonest, fraudulent, criminal or malicious act(s) or omission(s) of any officer or employee.)  Please select the limit of cover you require
Do you require loss of documents cover? (Cost of restoring, replacing or reconstituting documents)
Do you require cover for legal costs of representation at investigations and examinations e.g. Charity Commission?
Do you require cover for Public Liability Insurance?
Do you require professional indemnity cover for any advice you provide? If yes please provide detail of advice type given
Do you  run residential homes and/or provide regular care, supervision, etc for minors or vulnerable adults? If yes please provide detail
Do you have any trading subsidiaries?  If yes please provide detail
Please provide your charity or company registration number
If you have previously held this type of insurance, please give the date that cover first started
Do you provide any form of medical or surgical treatment, care or advice or undertake any scientific or medical research or undertake any certification, examination, licensing or regulatory activities, responsibilities or functions? If yes please provide details
Please advise the number of employees and volunteers with responsibility for money and/or accounts and/or goods and/or computer operations
In the past five years, have you had any claims made against any Director, Officer or the Company or are you aware of any circumstances or incidents that could give rise to a claim being made against them whether or not the circumstance or incident has been notified to an insurer? If yes, please give details:
Please advise of any other information you feel may be relevant (including any incidents or claims that have happened) or any other specific information you wish us to provide with any quotations.

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