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COMBINED MARKET TRADERS INSURANCE ASSOCIATION

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									          COMBINED MARKET TRADERS INSURANCE ASSOCIATION
9 St Edmunds Road                                                      12 Warren Court
Gants Hill                                                             Manor Road
Ilford, Essex                                                          Chigwell Essex
IG1 3QL                                                                IG7 5EW
Tel: 0208 554 5273                                                     Tel: 0208 500 8489
Fax: 0208 924 3082                                                     Fax: 0208 500 2082
                                                                       Email:cmtia@btinternet.com

                                                  APPLICATION FORM
PUBLIC AND PRODUCTS LIABILITY COVER £5,000,000 - £48.00 (inclusive of £2.50 admin charge and insurance premium tax)
EMPLOYERS LIABILITY COVER           £10,000,000 - £25.00 (inclusive of insurance premium tax at 6%) YES/NO
                                    £5,000,000 - For cover against acts of terrorism

Public/Products Liability £5,000,000 any one occurrence and in the aggregate in respect of Products Liability and Pollution claims.
Please make your cheque/postal order payable to Combined Market Traders Insurance Association. Most major credit cards taken.


                                 PLEASE COMPLETE IN LEGIBLE CAPITAL LETTERS

PROPOSED FULL NAME AND TRADING NAME (IF ANY) FOR CERTIFICATE:

MR/MRS/MISS/MS              ________________________________________________________________________________

ADDRESS:                    ________________________________________________________________________________

                            ________________________________________________________________________________

                            ____________________________________________POSTCODE:_________________________

TEL NO:                     __________________________________EMAIL:_______________________________________

MAIN MARKETS
WORKED:                     ________________________________________________________________________________

PRODUCTS SOLD:              ________________________________________________________________________________
(Details must be given)

Products Liability Insurance does not apply to the sale of used or second hand electrical goods (including factory
seconds) nor the sale of food from mobile vehicles unless on a licensed pitch.

Have you, in respect of the cover to which this proposal relates, had insurance declined, cancelled, refused renewal        YES/NO
or subject to special terms?

Have you been convicted or charged with a criminal offence (excluding motor) or been declared bankrupt or insolvent         YES/NO

Have you had within the last 5 years any employers, public or products liability claim whether insured or not?              YES/NO

If Employers Liability Insurance requested, please advise maximum number of employees at any one time                     ________

NOTE: Cover only applies to one stall per market

If YES to any of the above please provide full details and indicate question to which your answer applies. Please continue on a
plain sheet of paper if necessary.




 Signed:                                                                                            Date:
No Cover is operative until this application has been accepted.                               Amount Rec’d

								
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