Name of Contact *(required)

Position*

Email Address*

Company Name*

Company Reg No

Telephone No*

What goods/service do you provide?

Do you have existing credit insurance policies?
YesNo

If yes (answer questions in italics)

Name of insurer

Type of indication required
select type of indicationUnited KingdomExportCombineSingle Risk

Anticipated INSURABLE TURNOVER over the next 12 months (£)

How many customers do you allow a credit limit of over £500 to?*

Maximum amount any client is likely to owe you at any one time (£)*

Have you suffered any bad debts in the last 3 years*
YesNo

IF YES PLEASE COMPLETE THE FOLLOWING

Total INSURABLE TURNOVER for the past 3 years (£)

Total BAD DEBTS for this period

Value of largest debt in this period (£)