CHARITY TRUSTEES LIABILITY INSURANCE PROPOSAL FORM

Transcription

1 CHARITY TRUSTEES LIABILITY INSURANCE PROPOSAL FORM Please Note: This is a proposal form for a policy relating to claims made against the Insured during the period of the policy only CLAIMS MADE. Please answer all the questions giving full and complete answers. Please use a separate sheet of paper if insufficient space. If necessary please write additional relevant facts on a separate sheet of paper. The proposal form must be completed and signed & dated by a person who is of legal capacity and have the authorisation to request this insurance for the Proposer. This form does not bind the Proposer but will form part of the Insurance contract if taken up. All material facts must be disclosed, as failure to do so may render any policy or certificate voidable, or severely prejudice your rights in the event of any claim. A material fact is one likely to influence acceptance or assessment of the proposal by Underwriters. If you are in doubt as to what constitutes a material fact, you should consult your broker. Please supply the following additional information: A copy of the Charity s last issued reports and accounts A copy of the Trust deed, constitution or memorandum or Articles of Association A copy of any publication or newsletter put out by the Charity All questions must be answered to enable a quotation to be given. The completion of this Proposal Form does not bind the Proposers or the Underwriters to complete a Contract of Insurance. If there is insufficient space to answer questions, please use an additional sheet and attach it to this form (please indicate question number). Page 1 of 9

2 1. (a) Name of Charity (b) Address of the Charity Postcode: Tel No: ( ) Fax No: ( ) address: Website Address: (c) Date Charity was established (d) Charity Number 2. Type of Charity (e.g. Trust, Limited Liability Company, Industrial/Provident Society, Unincorporated Association/Trust, Incorporated by Royal Charter). 3. Please attach full details of the Governors, Trustees, Directors of the Company and/or Officers of the Charity (hereinafter referred to as the Proposers). 4. Number of Qualified Number of Employees (ii) (iii) All other Employees Voluntary workers engaged in charitable work other than fund-raising 5. Please summarise the activities of the Charity 6. Does the Charity s activities extend overseas? Page 2 of 9

3 If Yes, please advise in what manner and in which countries 7. How are the Charity s investments managed? By Professional Managers If Yes, please state name (ii) Directly by Trustees 8. Are you able to confirm that the Charity s activities are solely confined to fund raising and/or provision of advice or support to an identifiable group or community, and that such advice and support (a) does not involve proving any form of treatment and/or medical/surgical care or advice? (b) does not involve providing any legal, financial or environmental advice? (c) does not involve undertaking any scientific or medical research? (d) is free of any specific charge or fee and is not the subject of a contract for the provision of professional services? OR (ii) that the Charity is either a sports, social or recreational society, association or club? AND THAT (iii) the Charity does not undertake any certification, examination, licensing or regulatory activities or functions? If No, please provide full details 9. Do the activities of the Charity involve either Page 3 of 9

4 the provision or running of residential homes for, and/or (ii) the regular care of, training, supervision or sole charge of persons under the age of 18, or of vulnerable adults, by members, employees or volunteers of the Charity? If Yes, please answer the following questions (a) Please provide full details of the Charity s activities N.B Please answer all subsequent questions in relation to all parties to be insured (b) Please provide full details of the Charity s policies and procedures to ensure the suitability of such members, employees or volunteers to work with children or vulnerable adults 10. (a) What is the Charity s total gross income for the last complete financial year? (b) Provide a percentage breakdown of the source of such income between (ii) (iii) (iv) (v) (vii) Funding from Government, Local Authorities or Government/Local Authority agencies Subscriptions and membership fees Voluntary income/donations Fee-generating activities - please complete question (c) below Other - please complete question (c) below TOTAL 100 (c) If income is derived from fee-generating activities or other sources please provide full details Page 4 of 9

5 NB you are only insured for those activities declared 11. Do you agree with the following statements? you do not anticipate any major changes in these activities in the forthcoming twelve months Agree Disagree (ii) there have been no fundamental changes in the Charity s activities over the last five years Agree Disagree (iii) the Charity s total gross income from each of its last three financial years and its estimated gross income from its current financial year does not vary from one successive year to another by more than + 25? Agree Disagree (iv) no work is undertaken or activities conducted outside the United Kingdom Agree Disagree If you Disagree, please provide details 12. (a) Can you confirm that the Charity s funds are managed by suitably qualified external professional managers? If Yes please answer question 12(b) below If No please answer question 12(c) below (b) Can you confirm that (ii) there has been no change in the external professional managers used by the Charity within the last three years? the Charity and/or its Trustees maintain full legal rights against such external professional managers? If No to 12(b) please provide full details: (c) Please provide full details of who manages the Charity s funds, the length of time they have undertaken and their experience in, fulfilling this function Page 5 of 9

6 13. Can you confirm the following good practice in respect of all the Charity s locations? all money received by inside staff or volunteers is recorded and banked daily (ii) employees and volunteers are required to account for money received at least weekly (iii) petty cash payments are always made against authorised vouchers (iv) cash in hand and petty cash are checked independently of the employees/volunteers responsible at least monthly and additionally, without warning, at least every six months (v) salaries/wages not paid by credit transfer or crossed cheque are checked independently of the employees/ volunteers handling such money (vi) all payments, other than petty cash and salaries/wages, are made by crossed cheque (vii) cheques are prepared independently of the signatory to a cheque (viii) the signatory to a cheque always examines full supporting evidence (ix) pre-signed cheques are not used (x) different employees/volunteers, acting independently, are responsible for ordering, certifying receipt of and authorising payment for goods and services (xi) on an at least annual basis physical stock and inventory checks are carried out independently of employees/ volunteers responsible for the stock If No to any of the above please provide details of your system (xii) are bank statements, receipts, counterfoils and supporting documents checked at least monthly against cash book entries independently of the person making the cash book entries or paying into the bank? (xiii)has any person the authority to issue cheques bearing his/her signature alone? If Yes please state by whom and up to what amount 14. Are written references obtained in respect of employees responsible for the handling of monies? Page 6 of 9

7 15. Has the Charity suffered any loss during the past five years through fraud or dishonesty of any employee? If Yes please provide details 16. Have any complaints concerning the Charity been made to the Charity Commissioners? If Yes please provide details 17. Has the Charity ever been, or is the Charity currently subject to an investigation by the Charity Commissioners or other official Body or Institution? If Yes please provide details 18. Does the Charity currently hold or has the Charity previously held Trustees Liability Insurance during the past three years? If Yes please state the name of the Insurers (ii) the expiry date of the policy (DD/MM/YY) (iii) the limit of Indemnity (iv) the Excess (v) the Premium (vi) the Expiry Retroactive Date (DD/MM/YY) 19. As far as is known, have the Proposers or their predecessors ever been refused this type of insurance or had a similar type of insurance cancelled? If Yes please provide full details Page 7 of 9

8 20. What indemnity limit is required? 250, ,000 1,000,000 Other (please specify) 21. (a) Have any claims been made against the Charity and/or Proposers that would have fallen within the scope of the proposed insurance if such insurance had been in force? If Yes please provide full details (b) Are any of the Proposers, after enquiry, aware of any circumstances or incident which he/she has reason to believe might afford grounds for any future claim such as would fall within the scope of the proposed insurance? PLEASE NOW SIGN THE DECLARATION OVERLEAF Page 8 of 9

9 DECLARATION I, the undersigned, being a Trustee of Officer of the Charity referred to in Item1(a) of this proposal. Hereby declare that:- 1. I am authorised to complete this proposal form on behalf of the Charity referred to in Item 1 of this proposal and any other body declared therein; and 2. All answers to the questions contained in this proposal are, AFTER ENQUIRY, true and correct to the best of my knowledge and belief;- 3. I understand that the submission of this proposal does not bind either the Underwriters of the Charity specified in Item 1 to enter into a binding contract of insurance. Signature:. Name:.. Position Date. Please submit with this proposal form the following:- (ii) (iii) A copy of the Charity s last issued reports and accounts A copy of the Trust deed, constitution or memorandum or Articles of Association A copy of any publication or newsletter put out by the Charity Page 9 of 9