Liability Insurance Proposal Form
Liability Insurance Proposal Form Proposer 1.
Full Name (including trading name and names of all partners and if applicable, any subsidiary companies)
Your Employer Reference Number (commonly known as Employer PAYE Reference) 2.
Postal Address
Post Code Telephone Number Fax Number Email address Business 3.
Description of all your business activities
Date business Established
Cover – please select the cover you require 4.
Employers Liability
Limit of Indemnity £10m
Public/Products Liability
Limit of Indemnity
YES
£1m
£2m
NO
£5m
Financial Information 5.
Please state the number of people working and the annual estimated wageroll/remuneration, split between the following:Number of people
6.
a)
Clerical Employees and Principals/Directors not undertaking manual work
b)
Principals/Directors undertaking manual work
c)
Employees undertaking manual work
d)
Labour-only Sub-contractors
e)
Bona-fide Subcontractors (who have their own insurances)
f)
Temporary Employees
Wageroll/remuneration
i) Number ii) Days employed per annum
Annual Fee Income General Questions
7.
Is any work undertaken away from your premises/office? If “Yes”, please give full details of the nature and location of this work.
8.
Is any work undertaken in Eire or otherwise outside the UK?
9.
Does your work involve the use or handling of any goods known to be potentially harmful to health or that require a hazard warning?
YES
YES
/ NO
/ NO
YES
/ NO
If “Yes”, please provide details, including safety measures used
10.
Does your work involve any of the following: a)
the application of heat
YES
/ NO
b)
powered machinery or tools
YES
/ NO
c)
work at height above 10 metres
YES
/ NO
d)
digging/working below ground level
YES
/ NO
YES
/ NO
If “Yes”, give details of work and maximum depth limit
e)
work in or on Tunnels, Chimneys, Shafts, Mines, Steeples, Quarries, Towers, or similar If “Yes”, please provide full details
11.
Have you or any Principals or Directors in the business or any company in which you or such Principal or Directors have or had an interest:
a)
Ever been refused insurance or had any special terms or conditions imposed by an insurer?
YES
/ NO
b)
Ever been convicted of or is any prosecution pending for any offence involving fraud, arson, theft, wilful damage or handling stolen goods?
YES
/ NO
c)
Ever been declared bankrupt, the subject of bankruptcy proceedings, insolvency, administration or winding up?
YES
/ NO
d)
Ever been prosecuted or awaiting intended prosecution under any Health & Safety At Work Act or Consumer Protection Act?
YES
/ NO
Claims
12.
Please give details below of all losses and claims, involving injury to employees or other persons, or third party property damage, during the last six years, whether insured or not. Please provide details of the amounts paid as compensation and/or the amount reserved by insurers:Nature of Claim/Loss
Amount Paid/Reserved
DISCLOSURE • You have a legal duty to disclose to insurers all material information which may affect their judgement in determining whether to provide you with insurance and if so on what terms. In the case of renewal of existing insurance arrangements, this includes any material changes to information already disclosed to insurers; • If you are in any doubt as to whether or not information is material, you should disclose it, even if there is no specific relevant question in the proposal form; • Failure to disclose material information may give insurers the right to avoid any contract of insurance they may subsequently issue, with the consequence that you will not be protected for any claims notified under that insurance. DECLARATION I / We declare that the above statements and particulars are true and I / We have not suppressed or mis-stated any material facts. I / We agree that this proposal, together with any other information supplied by me / us shall form the basis of any subsequent contract of insurance. I / We agree that where information has been inserted on our behalf, we have reviewed such information and confirm the information is accurate and correct Signed:
Partner / Director / Practitioner
For and on behalf of:
Date: Important: Please note that we are unable to place Liability insurance in isolation. You must also place your Professional Indemnity insurance with ourselves.
Full Name (including trading name and names of all partners and if applicable, any subsidiary companies)
Your Employer Reference Number (commonly known as Employer PAYE Reference) 2.
Postal Address
Post Code Telephone Number Fax Number Email address Business 3.
Description of all your business activities
Date business Established
Cover – please select the cover you require 4.
Employers Liability
Limit of Indemnity £10m
Public/Products Liability
Limit of Indemnity
YES
£1m
£2m
NO
£5m
Financial Information 5.
Please state the number of people working and the annual estimated wageroll/remuneration, split between the following:Number of people
6.
a)
Clerical Employees and Principals/Directors not undertaking manual work
b)
Principals/Directors undertaking manual work
c)
Employees undertaking manual work
d)
Labour-only Sub-contractors
e)
Bona-fide Subcontractors (who have their own insurances)
f)
Temporary Employees
Wageroll/remuneration
i) Number ii) Days employed per annum
Annual Fee Income General Questions
7.
Is any work undertaken away from your premises/office? If “Yes”, please give full details of the nature and location of this work.
8.
Is any work undertaken in Eire or otherwise outside the UK?
9.
Does your work involve the use or handling of any goods known to be potentially harmful to health or that require a hazard warning?
YES
YES
/ NO
/ NO
YES
/ NO
If “Yes”, please provide details, including safety measures used
10.
Does your work involve any of the following: a)
the application of heat
YES
/ NO
b)
powered machinery or tools
YES
/ NO
c)
work at height above 10 metres
YES
/ NO
d)
digging/working below ground level
YES
/ NO
YES
/ NO
If “Yes”, give details of work and maximum depth limit
e)
work in or on Tunnels, Chimneys, Shafts, Mines, Steeples, Quarries, Towers, or similar If “Yes”, please provide full details
11.
Have you or any Principals or Directors in the business or any company in which you or such Principal or Directors have or had an interest:
a)
Ever been refused insurance or had any special terms or conditions imposed by an insurer?
YES
/ NO
b)
Ever been convicted of or is any prosecution pending for any offence involving fraud, arson, theft, wilful damage or handling stolen goods?
YES
/ NO
c)
Ever been declared bankrupt, the subject of bankruptcy proceedings, insolvency, administration or winding up?
YES
/ NO
d)
Ever been prosecuted or awaiting intended prosecution under any Health & Safety At Work Act or Consumer Protection Act?
YES
/ NO
Claims
12.
Please give details below of all losses and claims, involving injury to employees or other persons, or third party property damage, during the last six years, whether insured or not. Please provide details of the amounts paid as compensation and/or the amount reserved by insurers:Nature of Claim/Loss
Amount Paid/Reserved
DISCLOSURE • You have a legal duty to disclose to insurers all material information which may affect their judgement in determining whether to provide you with insurance and if so on what terms. In the case of renewal of existing insurance arrangements, this includes any material changes to information already disclosed to insurers; • If you are in any doubt as to whether or not information is material, you should disclose it, even if there is no specific relevant question in the proposal form; • Failure to disclose material information may give insurers the right to avoid any contract of insurance they may subsequently issue, with the consequence that you will not be protected for any claims notified under that insurance. DECLARATION I / We declare that the above statements and particulars are true and I / We have not suppressed or mis-stated any material facts. I / We agree that this proposal, together with any other information supplied by me / us shall form the basis of any subsequent contract of insurance. I / We agree that where information has been inserted on our behalf, we have reviewed such information and confirm the information is accurate and correct Signed:
Partner / Director / Practitioner
For and on behalf of:
Date: Important: Please note that we are unable to place Liability insurance in isolation. You must also place your Professional Indemnity insurance with ourselves.
