Pop Up Insurance Form

For a no-obligation quote, please complete this form and we will aim to get back to you on the same working day.

Our insurer is unable to quote more than 30 days in advance. If you request a quote for a future period you will receive your quote 30 days prior to the cover start date.

For the purposes of your quote we will assume that you have not:

– had any convictions or criminal offences which are not spent under the Rehabilitation of Offenders Act or has any prosecutions pending
– been declared bankrupt or insolvent or been the subject of bankruptcy proceedings or insolvency proceedings
– had a proposal refused or declined
– had an insurance cancelled
– had a renewal refused
– had special terms imposed

If this is not the case, please provide details in the ‘Notes’ section below.

    Period of cover (starting)

    Period of cover (ending)


    Status of entity

    Any insurance claims paid or outstanding in the last 5 years?

    Material Facts – Tick those that apply

    Is there an intruder alarm?

    Accreditation of intruder alarm & Maintenance contract accreditation

    Under the sole control of proposer

    Alarm type

    Police Response

    Does the alarm incorporate confirmable technology

    Other Security Measures – Tick those that apply

    Public Liability Cover

    Employers Liability cover - Employer's Liability cover of £10,000,000 is automatically included at no extra cost

    Contact details

    Branch Location:
    Regus Civic Building,
    2nd Floor,
    323 High Street,
    Epping, Essex,
    CM16 4BZ


    W B Baxter is a trading name of Adler Fairways Insurance Brokers Limited. Adler Fairways Insurance Brokers Limited is authorised and regulated by the Financial Conduct Authority under FRN Number 309236. You may check this on the Financial Services Register by visiting the FCA’s website, www.fca.org.uk/register/ or by contacting the FCA on 0800 111 6768. Adler Fairways Insurance Brokers Limited is registered in England and Wales under registration number 04525948. Our registered address is Number 22 Mount Ephraim, Tunbridge Wells, Kent TN4 8AS.