Commercial Insurance Quote Name of Business Address Post Code eMail Telephone Mobile Person to contact Best time for contact? Because of the intricacy of commercial insurance products, it is impossible for us to ask you all the relevant questions on this web site. As you will have already read from our web site, we would prefer to discuss this by telephone or face to face. We would therefore be grateful if you could complete the relevant questions on this enquiry form, in order to give some initial information. Trade Description / occupation What type of insurance are you interested in? Factories Public Liability Employers Liability Professional Indemnity Motor Fleets Hotels, Restaurant, Pubs Shops, Offices, Surgeries Motor Trade Residential Homes Other (please write in comments box) Is this a new business set up? Yes   No Are you already Insured? Yes   No What is the renewal date of your current Insurance? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   January February March April May June July August September October November December   2007 2008 2009 2010 2011 > 5 years   Or what date do you need cover from? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   January February March April May June July August September October November December   2007 2008 2009 2010 2011 > 5 years   Are you happy with your current Insurance Broker/intermediary? Yes   No Comments WHITE KNIGHT GROUP Britannia House High Street Bream, Lydney Glos GL15 6JS Tel 01594 563288 Fax 01594 564084 Email brianfrost@whiteknightgroup.co.uk FSA number is 121356 White Knight Group is an independent intermediary authorised and regulated by The Financial Services Authority who also trade under the names of Dean Magna Insurance & Financial Consultants, Farmer & Clark Insurance & Financial Consultants, Swambo Woollett Insurance & Financial Consultants and Newent Insurance Services. Please refer to www.fsa.gov.uk for further information.

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