Online Quote Application Form - Information Technology

We have tried to keep this application as brief as possible so it should take you no more than 3 minutes to complete. Fields marked with * are compulsory fields.

Business Details
Business Name *
Your Name*
E-mail Address *
Main Business Activity *	Application Service ProviderDigital Marketing AgencyDomain Name RegistrarEncryption SoftwareHardware ManufacturerIT ConsultantIT RecruitmentIT Security ConsultantIT TrainingInternet Service ProviderMobile Content ProviderSoftware DeveloperValue Added ResellerWeb DeveloperWeb Hosting ResellerWeb Hosting (Own Servers)Other
If Other Please Specify
Address Line 1*
Address Line 2
Address Line 3
City / Town *
Post Code *
Telephone No *
Cover Details:
Do you hold a current professional indemnity policy? *	Yes No
If 'YES' please provide the retroactive date of your existing policy:
Current Professional Indemnity Insurer
Total number of employees: *	1-23-45-78-10More than 10
Last completed year turnover: *	Less than £100k£100k-£499k£500k-£999k£1m-£2mMore than £2m
Actual Turnover Last Year/Anticipated Turnover If New Business
% Sales from USA/Canada: *	No USA/Canada SalesLess than 15%15% or more
Cover Requirements:
Professional Indemnity Cover Required: *	£100,000£250,000£500,000£1m£2m£5m
Employers' Liability Cover Required: *	Not Required£10m
Public & Products Liability Cover Required: *	£1m£2m£5m
General Office Equipment Cover Required (At Premises):
Fixed Computers (At Premises):
Portable Computers (Worldwide):
Business Interruption (Flexible Loss Limit):	£ 1,000£ 2,000£ 5,000£ 10,000£ 20,000£ 50,000£100,000

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