Quotation Request Insurance Backed Guarantee Agent Client Details Risk Details General Questions Cover Details Hidden AgentAre you an Agent? YesNo This form should be completed on behalf of the contractor that will be responsible for issuing the written guarantee that the required insurance policy will be backing. If you are not the contractor you can copy the link below and pass it to the contractor.https://blg.schemeserve.com/schemeserve/admin/questions/edit.aspx?schemeId=SCHEME_ID_7679 What is your name? What is your email address? Please confirm that you have read our Terms of Business Agreement Client DetailsName -- Mr Mrs Miss Ms Dr Prof. Capt. Lord Lady Major Rev. Master Exec(s) of Mx Address UDPRN UPRN Organisation Line 1 Line 2 Town/City County Postcode Enter address manually or Enter address manually Use address lookup Telephone Email Email Email enter again Contractor Details Company Name Is the Contractor Address the same as the Proposer Address? YesNo Address UDPRN UPRN Organisation Line 1 Line 2 Town/City County Postcode Enter address manually or Enter address manually Use address lookup Registered Number Trade Body Member Risk Details Beneficiary of Contractor's Guarantee Name Do you know the Beneficiary Address? YesNo Is the Beneficiary Address the same as the Proposer Address? YesNo Address UDPRN UPRN Organisation Line 1 Line 2 Town/City County Postcode Enter address manually or Enter address manually Use address lookup Risk AddressDetails of the premises where the contract is being undertaken Is the Risk Address the same as the Proposer Address? YesNo Address UDPRN UPRN Organisation Line 1 Line 2 Town/City County Postcode Enter address manually or Enter address manually Use address lookup Type of Premises No. of Storeys Above Ground No. of Storeys Below Ground Contract DetailsThe total sum insured should represent the total cost of replacement/rebuild of the Insured Works. This should include items such as access, enabling, etc., even if these did not form part of the original contract. Contract Value (incl. VAT) £ Access Costs (e.g. scaffolding) £ Enabling Works/Debris Removal/Professional Fees £ Total Sum Insured £ Start DateIf the Start Date is unknown please provide an estimated Start Date 01 02 03 04 05 06 07 08 09 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 2022 2023 2024 2025 2026 2027 2028 Completion DateIf the Completion Date is unknown please provide an estimated Completion Date 01 02 03 04 05 06 07 08 09 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 2022 2023 2024 2025 2026 2027 2028 Have the works already commenced? YesNo What was the reason that a warranty was not arranged prior to start on site? Description of WorksPlease provide as much detail as possible Is roofing included? YesNo Number of roofs? Materials and Design System Is the product BBA certified? YesNo Do the installers have a minimum of 5 years experience in installing these or similar products? YesNo Is the installer an approved installer for the product manufacturer? YesNo Who designed the Works? Cover Required Number of years - select - 1 2 3 4 5 6 7 8 9 10 11 12 Please select which type of cover is requiredMore than one option can be selected Workmanship Materials Design General QuestionsDuring the last three years have you carried out repair work due to defective workmanship or materials that you have installed previously? YesNo Please provide more details Does the contractor have any County Court Judgments against it in the last 5 years? YesNo Please provide more details Have you or any other director, principal or partner of the proposer been personally declared bankrupt, entered into an individual voluntary arrangement, involved in a company that has been, or is due to be declared bankrupt, ceased trading or entered into any form of liquidation? YesNo Please provide more details Have you or has any director, principal or partner of the proposer ever been convicted or is there any prosecution pending for any offence involving dishonesty of any kind? YesNo Please provide more details Have you or has any director, principal or partner of the proposer ever been convicted or is there any prosecution outstanding under the Health & Safety at Work Act 1974 or Consumer Protection Act 1987? YesNo Please provide more details Have you or has any director, principal or partner of the proposer ever been declined an application for the supply of insurance backed guarantees or had membership from any insurance backed guarantee provider cancelled? YesNo Please provide more details In relation to the property and/or development being proposed, are there any known circumstances or defects that may, or are likely to, give rise to a claim or have been the subject of a previous claim or remediation works? YesNo Please provide more details Terms & Conditions of Application You understand that details of the risk proposed will be passed to our panel of insurers and may then be passed on to a 3rd party surveying company. You understand that the insurers will receive an Electronic Report Summary (The Output) of the Limited Company, its Directors' personal credit file or for non-limited entities its Proprietor/Partners' personal credit file.You are aware that the search footprint retained by the credit reference agency in respect of the credit search made will show that a credit/identity check has been performed. You consent the search footprint to be retained by the credit reference agency in respect of a search made and will read as having been made by the insurer. You understand that the insurers have a valid reason for this search, this being ascertaining the suitability for an insurance backed guarantee.You understand that the Output will be treated as confidential and will be used solely by Building and Land Guarantees Ltd and the insurer. You confirm that by signing below you understand and agree to these terms and conditions of application. I agreeI don't agree DeclarationPlease confirm the below statement is true I have read over all of the statements and particulars given in this form (including any answer written for me by any other person) and I declare that to the best of my knowledge and belief they are correct and that no material fact has been omitted, misrepresented or mis-stated. I am not aware of any other circumstance likely to affect the risk. In consideration of the Insurer's acceptance I agree to be bound by the terms and conditions of the Policy that includes the Contractor being contractually obliged to the Insurer to make good all defects reported if they are trading. I have provided a copy of this form to the Insured company/individual and have noted that, where a technical inspection maybe required, full access will be provided to the technical inspector. Name Position Cover Details Total Premium (Net) £0.00 + IPT @ % £0.00 + Policy Fee £ £0.00 Total Premium £0.00 Total Commission £0.00 (Due From Broker) £0.00 HiddenFee £