1. Company Details
1.1. Please state the name and address of the principal Company for whom this insurance is required. Cover is also provided for the subsidiaries of the principal Company, but only if you include the data from all of these subsidiaries in your answers to all of the questions in this form.
 Insured Company
 Contact Name
 Address
 Telephone
 Fax
 Email Address
 Website
 
1.2. Please state when your company was established
 
1.3. i) How many directors and / or partners are there in the Company?
ii) Please state below the details of all Partners / Directors.
NameYears in PositionYears ExperienceQualifications
  
  
  
  
iii) Please state the number of employees
    Marketing / Sales / Business Development
    I.T. / Technical
    Other
 
1.4. Please state your fees received in respect of the following years:
  Currency
      Date of Financial Year End (dd/mm)
 
Last Complete
Financial Year		Estimate for Current
Financial Year		Estimate for Next
Financial Year
  (a) Domestic Turnover
  (b) USA Turnover
  (c) Other Territory Turnover
  Total Turnover
  Operating Profit / Loss
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Registered in England: Number 608819
Authorised and Regulated by the Financial Services Authority
Registered Office:
Lygon House, 50 London Road, Bromley, Kent. BR1 3RA