EFCIS - Credit Insurance Enquiry Form

Online Enquiry Form

Contact Information

Name:
Position:
Telephone No:
Email address:

Company Information

Company Name:
Company Registered Number:
Address:
Description of Business Trade:

Business Information

		Estimated for next 12 months		Last 12 months		Previous 12 months		Previous 12 months
Sales UK:
Sales Export:
Total Bad Debts:
Largest Loss:
Number of Losses:
Accounting Period:

Your Customers

Please provide us with your top 5 customers you require cover on:

Company Name		Registration No (or address if unlimited)		Credit Limit Required

Other

Please provide any additional information below:

Declaration

We confirm that the information provided in this questionnaire is correct to the best of our knowledge and belief. We are not aware of any other circumstances which might influence insurer's acceptance of this risk.

Please tick :

We're committed to keeping your customer data confidential and will process any information you give us in accordance with the Data Protection Act 1998. The Data Protection Act 1998 states that personal data must be processed fairly and lawfully. This means you have the right to know how we intend to use your personal data. You can then decide whether you want to provide the information