Alpha Recruitment Contractor/Temporary Worker Declaration

Lets get to know you

Full Name of Contractor/Temporary Worker (including t/a and LLC)

Are you on assignment as:

Independent Contractor

Temporary Worker

When does your contract start:

What would best describe your assignment (job role/title)

Prior history

Have you had any claims for professional negligence, errors or omissions in the past 5 years?

Yes

Have you had any disputes with payment of your fees in the past 5 years?

Yes

Declaration

After enquiry, I the undersigned, declare (insert your name in the box below)

I am authorised to make this Declaration

I have read this Declaration and acknowledge the contents is the same and to be true and complete.

I agree that this Declaration supplied by me/us shall form the basis of any contract of insurance effected thereon, and I undertake to inform the Insurer of any material alteration to these facts whether occurring before or after completion of such contra

I agree that i2i Brokers may use and disclose our personal information in accordance with the "Privacy Statement" at the beginning of this Declaration.

By ticking this box you agree you have signed your approval of the information disclosed and the use of I/We Accept is as reliable as is appropriate given the purpose for which, and in the circumstances in which a signature is required

i2i Insurance Brokers

Alpha Recruitment's Contractor/Temporary Worker Declaration

PRIVACY STATEMENT

Lets get to know you

Prior history

Declaration

i2i Insurance Brokers

Alpha Recruitment's Contractor/Temporary Worker Declaration

PRIVACY STATEMENT

Lets get to know you

Prior history

Declaration

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