Enquiry Form - Counsellors Insurance

Title *

First name *

Surname *

Name of limited company *

Address *

Postcode *

Phone number *

Email address *

Member of a professional body? *

Number of practitioners *

Activities to be covered *

Turnover *

Start date of policy *

Have you ever been convicted or charged with (but not yet tried), or been given an official police caution in respect of any offence other than a motoring offence? *

Yes

No

Have you ever been made bankrupt, insolvent or liquidated? *

Yes

No

Have you ever been served with any County Court Judgements, or other similar judgements in relation to debt? *

Yes

No

Have you ever had Insurance refused or declined? *

Yes

No

Have you ever had insurance cancelled or special terms imposed on those insurances? *

Yes

No

Have you, within the last five years, been prosecuted or served prohibition or improvement order under Health and Safety Legislation? *

Yes

No

Have you ever been disqualified from being a Company Director? *

Yes

No

Have any liability claims been made against you, or are you aware of any circumstances which may give rise to a claim? *

Yes

No

Have you made any claims including Legal Expenses or suffered any losses relating to this type on insurance within the last five years? *

Yes

No

Are you aware of any incidents which could give rise to a claim, or allegation against you at this time? *

Yes

No

Will you be practicing and residing wholly within the UK? *

Yes

No

Will you be working from home, visiting clients on their premises, or working from mutually agreed premises? *

Yes

No

Will you be selling any products in the course of your business activities? *

Yes

No

Do you provide training toward a formal qualification (this would not include CPD to already qualified practitioners)? *

Yes

No

Do you have the required qualifications (or working towards) and/or experience to be able to practice your business activities? *

Yes

No

Towergate Insurance is part of The Ardonagh Group. If you would like to receive the latest offers on selected financial and related products and services from Towergate Insurance and The Ardonagh Group, please choose how you would like us to contact you. If you would like to change your contact preferences at any time, please e-mail: caredivision@towergate.co.uk

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