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Client Details

  • Does your business have any subsidiary companies?

    Is the company exempt from requiring an HMRC PAYE Employers Reference Number?

  • General Information Details

    Claims

    Have you been involved in any incidents, suffered any losses or made any claims in the last 5 years for any of the covers requested?

    1

    £

    2

    £

    3

    £

    4

    £

    5

    £

    Cover Required

    Estimated Turnover Figures for the coming 12 months - Net of VAT for all your business activities

    Additional Information

    Other Details

    © Coversure Insurance Services 2020

    Mr Jeremy Burgess trading as Coversure Insurance Services (Reigate) is authorised and regulated
    by the Financial Conduct Authority. Ref: 307359.