Welcome to Waveney Insurance Brokers

Engineering Inspection Service

Complete the short form below to get a quotation or call 01473 269443

Renewal Details
Renewal Date		Select 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   Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2009 2010 2011		Renewal Premium
Customer Details
Clients Name				Trading Name
Telephone Number				Email
Building Name/Number				Postcode
Risk Address if different from Above
Items of Plant
Description of plant including make / model & serial number	Year Of Make		Date of Last inspection	Location of Plant in Surgery	New Replacement Value		Capacity
Cover
State the limit of indemnity (any one occurance) required if the standard £100,000 is inadequate				Are you aware of any defects in your items of plant		Select
If yes provide details
Claims Experience
Have you made any claims within the last 3 years		Select Yes No		Number of claims made		Select 1 2 3 4 5+
If yes please provide details of claims below
Claim Type		Date Of Claim		Payments made
It is true that no Insurer has declined your Proposal, cancelled or refused to renew your policy or required any special terms or conditions in respect of any of the risks proposed.		Select Yes No		If no please provide details
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