HSB Micro Renewable Insurance

Transcription

1 HSB Micro Renewable Insurance Proposal form Operational all risks cover for anaerobic digestion and biogas installations Please answer all of the following questions carefully, providing any additional information that is needed, continue on a separate sheet of paper if necessary. The answers you give in this proposal form together with any other information provided, will be used by us to determine whether we offer cover and, if so, the terms of your insurance. The answers you give must be complete, accurate and not misleading. This means you must tell us about all facts and matters that may be relevant to your insurance. If we find that you or anyone acting for you, have failed to give us relevant information, or have given us incorrect information, we may change the terms of your insurance or treat it as if it had never existed. If you have any questions please contact your insurance broker, or contact us. Any words or phrases which appear in bold will have either the meaning that is shown in the Definitions section of the policy or is a heading to help you find the information you need. A copy of the policy document is available on request. Customer details If there is more than one response to any of the following questions please list them all. The proposed insured Business description Contact name Business address (where we can contact you) Registered address (if different from Business address above) Telephone number address Who is your current insurer? What is the expiry date of your current insurance? What date do you want the proposed insurance to start? Location of the proposed insured property (if different from Business address above) Details of any party whose interest should be noted on the proposed insurance (If more than one, please continue in Other information ): Name Address Details of interest 1 STA-MIC Anaerobic and biogas proposal form-v1.0

2 Cover required (Please note section 1 is mandatory, section 2 is optional and section 3 is not available for this type of technology) Section of cover Cover required Sum insured Excess or time excess required Section 1 Equipment damage new replacement value for each occurrence Section 2 Loss of income estimated income days for each occurrence Section 3 Public liability t available for this type of technology Please complete the sections for which you require cover: Section 1 Equipment damage What is the total new replacement value of the proposed insured property? (i.e. combined heat and power unit (CHP) plus any substation and distribution transformer, switchgear, meter, cabling, telecommunication and monitoring device, building and converter housing (including fixtures and fittings), security equipment, access roads, hardstandings, fuel stock and spares.) Who is the manufacturer(s) of the main components? CHP Transformer Digestor tank Storage tank CHP Transformer Digestor tank Storage tank Is there a manufacturer s agent in the UK? What was the installation date of the proposed insured property? What is the age of the main components? CHP Transformer Digestor tank Storage tank What is the rated maximum output (kw) of the proposed insured property? Have you made any changes to the proposed insured property, which do not conform to the manufacturer s specifications? (If yes, please tell us about these changes in Other 2 STA-MIC Anaerobic and biogas proposal form-v1.0

3 information ) You must provide a plan of the proposed insured property, is it attached? How many gas engines are there in the CHP unit? Is there fire suppression / auto shutdown in the CHP unit? (If yes, please provide details of how the fire suppression / auto shutdown operates in Other information ) Where is the CHP unit located in relation to the digester tank? Have you taken any steps to prevent crusting in the digester tank? (If yes, please tell us about the steps taken in Other information ) Are there pressure release valves fitted on the digester tank? How many digesters are there in the proposed insured property? What is the distance from the digester(s) to the feed in substation? Does the proposed insured property have a valid warranty in place, which will continue throughout the period of insurance? What is the expiry date of warranty? Does the proposed insured property have a valid maintenance contract in place, which will continue throughout the period of insurance? What is the frequency of maintenance visits? Is there a guaranteed response time under the maintenance agreement? If yes, please state the agreed response time: Is there remote monitoring in place? If yes, please provide details: 3 STA-MIC Anaerobic and biogas proposal form-v1.0

4 Please provide details of security arrangements at the location of the proposed insured property (For example, fencing, alarm systems etc.) Please describe any significant features at the location of the proposed insured property (For example any hazardous activities nearby, history of extreme weather conditions or any waterbodies or watercourses nearby, etc.) Is there any history of flooding at the location of the proposed insured property? Please provide details of the transmission lines running from the proposed insured property to the grid (For example, distances, buried or hung overhead, etc.) Section 2 Loss of income What is your estimated annual income from the generation of energy (and any associated by-products) from the proposed insured property? What indemnity period do you require? months Please provide details of spare components kept at the location of the proposed insured property How long will it take to replace and install one of the main components (e.g. gas turbine, etc)? (Please include the manufacturing, delivery and installation time) 4 STA-MIC Anaerobic and biogas proposal form-v1.0

5 General information How long have you been in business? During the last 5 years, have you had any claim(s) or incident(s) that could have resulted in a claim under this policy? (If yes, please tell us about these claims or incidents in the table below) Date of claim or incident Brief details of claim or incident Total amount of loss arising from the claim or incident Have you or any director, officer or key person, whether in your/their own name, in the name of the business proposed or in the name of any other business in which any of you have had an interest: - been refused insurance or had any special term(s) or condition(s) imposed by an insurer in the last 5 years? - been convicted of or have any prosecution pending for any criminal offence(s) (for example criminal damage, arson, fraud, theft or handling stolen goods)? - been convicted of or have any prosecution(s) pending for any offence involving insurance fraud? - gone into bankruptcy, insolvency, liquidation, receivership or a similar procedure in the last 5 years or have such a procedure pending? - been criticised, fined, disciplined, suspended or expelled by any industry, trade association or regulatory body or have any such procedure pending? If you have answered yes to any of these questions then please provide full details in Other information. 5 STA-MIC Anaerobic and biogas proposal form-v1.0

6 Other information Please use this space to provide any additional information requested and to tell us about any other information you think may be relevant to us in relation to your proposal for HSB Micro Renewable Insurance (please continue on a separate sheet of paper if necessary): Please tick this box if you have attached additional information to this proposal form. 6 STA-MIC Anaerobic and biogas proposal form-v1.0

7 How we use your information We may use the information you give us for a number of reasons (for example, to make decisions about cover and claims, and to detect and prevent fraud). We may share your information with, and get information about you from, other insurers, credit-reference agencies, fraud-prevention agencies, regulatory authorities and agents who provide services on our behalf. We may share your information with third parties outside of the European Economic Area (EEA). If the information you give us is personal information (such as names, addresses, telephone numbers, job titles or dates of birth), you give us permission to use that information as explained above. If you give us personal information relating to anyone other than you, you must have that person s permission to give us their information and for us to use it as set out above. Declaration I/We declare that to the best of my/our knowledge and belief that this proposal form: - has been completed after a full and complete search for information; - is accurate and complete; and - discloses all facts and matters, which may be relevant to this proposal for insurance. I/We understand that the information provided in this form will be used by the insurer to determine whether to offer insurance and, if so, on what terms. I/We understand that non-disclosure or misrepresentation of a material fact or matter may entitle the insurer to avoid any contract of insurance or refuse any claim. I/We must notify insurers of any change to the information provided and understand that the terms of any insurance may be altered or withdrawn as a consequence of any change. Signature: (The person signing this application must be a director, officer or senior manager of the proposed insured if not the proposed insured) Name: Date: Your company position: You should keep a copy of this proposal form for your records. 7 STA-MIC Anaerobic and biogas proposal form-v1.0 HSB Engineering Insurance Limited, registered in England and Wales: , New London House, 6 London Street, London EC3R 7LP. Registered as a branch in Ireland: Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.