Application form quotations

Request easy quotes for your LifeScience startup below.

Application form for startups

Would you like to receive a quote for your startup regarding liability, business travel, intellectual property, or clinical trial insurance? Please fill out the request form below, and we will send you the quotes as soon as possible.

1. General liability (excluding products liability)

Answer the questions below and you’ll receive a quote for liability insurance shortly.

Company information

1. Company name

2. Trading name (if different)

3. Corporate address

4. Postal code

5. Chamber of commerce number (KvK)

6. Website

7. Locations (if other than the above)

8. Names companies to be insured

9. (Please explain relationship)

10. Please describe your activities as a (group of) company (companies), per insured entity (hoedanigheid)

Financial information

Please provide the following information for the past, current and future financial years:

11. Turnover past financial year (in €)

12. Turnover current financial year - estimated (in €)

13. Turnover next financial year - expected (in €)

14. Total number of employees

Employees division

Enter the ratio of your employees below:

15. Clerical / Managerial staff not involved in manual work %

16. Sales and marketing (in %)

17. Laboratory Workers (in %)

18. Manual workers (in %)

19. Other - please describe (in %)

20. Total estimated wage roll (in €)

21. Was a Risk Inventarisation and Evaluation (RI&E) survey performed? If yes, please attach report.

Yes
No

22. If yes: please upload your RI&E.

23. Do any of the applicant’s employees provide direct patient care?

Yes
No

24. Do they carry their own individual medical professional liability coverage?

Yes
No

25. Does the applicant operate an inpatient facility?

Yes
No

26. Does the applicant or its employees have a financial interest in the products of the applicants clients?

Yes
No

27. Is there a Clinical Trial planned in this or next year?

Yes
No

28. List new products expected to be introduced.

29. List any discontinued products. (please indicate reason(s)

Historic loss

30. Do you have any historic losses and/or circumstances that can lead to a loss?

Yes
No

31. If yes, please describe

32. Please enclose any documents, lists or explanations, as required, in response to various questions throughout the body if this insurance proposal. Please also provide copies of the following: Marketing or advertising brochures or descriptive mater.

33. Agreement for application.

I give hereby my agreement for this application.

34. Name

35. Position in company

36. E-mail

37. Telephone number

38. Date

Declaration

I/we declare that, after full enquiry, the contents of this proposal are true and that I/we have not misstated, omitted or suppressed any material fact or information. I/we agree that this proposal together with any other information supplied by me/us shall form the basis of any contract of insurance which may be effected. If there is any material alteration to the facts and information which I/we have provided or any new material matter arises before the completion of the contract of Insurance, I/we undertake to inform Underwriters.

All questions must be answered and the application must be signed and dated.

39. Agreement *

I agree

Simple and transparent

We like to keep insurance simple and transparent

2. Intellectual property insurance

Answer the questions below and you’ll receive a quote for intellectual property insurance shortly.

1. Company name

2. Address

3. E-mail and telephone number

4. In which country is your revenue generated?

5. What is the revenue forecast for the next 12 months? *

6. Have you ever needed legal advice regarding an IP dispute? *

7. Is there now grounds for a potential IP claim? *

8. Agreement for application.

I give hereby my agreement for this application.

9. Agreement *

I agree

LifeScience startups

We are specialized in insurances for LifeScience startups.

3. Business Travel insurance

Answer the questions below and you’ll receive a quote for business travel insurance shortly.

1. Company name

2. Address

3. E-mail and telephone number

4. What's your Chamber of Commerce number?

5. How many days a year are spent on business travel? *

6. Agreement for application.

I give hereby my agreement for this application.

7. Agreement *

I agree

Looking for the right insurance?

Feel free to call us. We are happy to help.

More information

If you have any questions or would like to discuss your options first, please feel free to call us. Rob Verkaik will be happy to help you find the right liability insurance for your LifeScience startup. He can be reached by phone at 06-48683015 or by email at rverkaik@simtra.nl.