COMBINED MARKET TRADERS INSURANCE ASSOCIATION

9 St Edmunds Road Gants Hill Ilford, Essex IG1 3QL Tel: 0208 554 5273 Fax: 0208 924 3082 12 Warren Court Manor Road Chigwell Essex IG7 5EW Tel: 0208 500 8489 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: MAIN MARKETS WORKED: PRODUCTS SOLD:
(Details must be given)

__________________________________EMAIL:_______________________________________

________________________________________________________________________________ ________________________________________________________________________________

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 or subject to special terms? Have you been convicted or charged with a criminal offence (excluding motor) or been declared bankrupt or insolvent Have you had within the last 5 years any employers, public or products liability claim whether insured or not? 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.
YES/NO

YES/NO YES/NO

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Signed: No Cover is operative until this application has been accepted.

Date: Amount Recd