Employer Liability Insurance Application Form

Employer Details

Person Receiving Care / Support

Correspondence Address

Additional Person(s) Receiving Care / Support

Policy Options

I have never had a proposal or renewal for insurance declined or had special terms imposed or suffered any claims in the last 5 years in respect of cover offered by this insurance. I undertake to advise the insurer as soon as possible of any changes to the information provided in this application. I agree that any information provided to the insurer regarding me for the purposes of accepting insurance and handling any claims may, if necessary, be divulged to third parties, provided it will be processed by the insurer in compliance with the provisions of the Data Protection Act 2018.