Proposal Form. Traders Combined. Commercial Division

Transcription

1 Proposal Form Traders Combined Commercial Division

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3 Traders Combined Policy A Policy designed to meet the needs of commercial and industrial businesses by offering a flexible range of cover. If your turnover does not exceed 2,000,000 we may be able to provide a quotation for our Business Cover package policy please ask for details. The Traders Combined Policy is not suitable for Precision Engineers with turnover less than 5,000,000, the Plastics industry and Motor Traders, for which more specific policies are available. Key Facts If required, a summary of the cover available can be provided by your broker or agent in the form of a Key Facts document. A specimen copy of the Traders Combined policy booklet can be provided on request. Methods of Payment You can pay your premium in full, via your broker or agent. Alternatively, if your premium is 100 or more, you can choose to pay by monthly instalments. Paying by NIG s flexible instalment scheme can ease your cash flow by spreading the premium payments. A 20% deposit is required with the balance, plus a credit charge, being spread over 10 equal monthly instalments commencing one month after the date cover commences. Your broker or agent can advise you on the amount of the charge and the interest rate it is based on. Important Note You (or the broker or agent completing the form on your behalf) must provide all material information likely to influence the acceptance and assessment of this insurance. If you have any doubts as to whether a fact is material you should disclose it. Failure to disclose any material fact may invalidate your policy or may result in your policy not operating fully. Please note that the proposal form, declaration and the additional information on the insurance provided by you (or the broker or agent acting on your behalf) will be the basis of the contract between us. NIG Traders Combined Proposal Form 1

4 FOR INTERNAL USE ONLY Agent Name Agency Code When completing this form, please tick the appropriate boxes and answer all questions in BLOCK CAPITALS YOUR INFORMATION For details of how we use the Proposers information, please look for the (padlock) symbol below and in the accompanying Terms and Conditions. PROPOSERS DETAILS Full Name of Proposer (Please show names of all companies to be insured including all subsidiaries; if not a limited company, full names of all partners) Company Registration Number Trading Name Postal Address Situation of property to be insured if different from above Web Site Address Business Description www. Post Code Post Code Business Phone No Survey Contact Name / / Period of Insurance Inception Date Renewal Date / / Sensitive Information Some of the personal information we ask you for may be sensitive personal data, as defined by the Data Protection Act 1998 (such as information about criminal convictions and civil proceedings). We will not use such sensitive personal data about you or others except for the specific purpose for which you provide it and to provide the services described in your policy documents. GENERAL QUESTIONS 1 In respect of the covers proposed, have you or any director or partner, either in the name of the business proposed or in the name of any other business in which any of you have had an interest a ever been insured? YES NO b ever had a proposal for insurance declined, renewal refused, cover terminated, increased premium required or special conditions imposed by any insurer? YES NO c sustained any loss or had any claim made against you, whether insured or not, during the last 5 years? YES NO IF YOU HAVE TICKED ANY OF THE SHADED BOXES, PLEASE GIVE DETAILS ON PAGE 3. 2 NIG Traders Combined Proposal Form

5 GENERAL QUESTIONS - continued 2 Either personally or in any business capacity, have you or any director or partner in the business proposed ever been a convicted of or charged (but not yet tried) with i a breach of any health and safety legislation? YES NO ii any other criminal offence other than a motoring offence? YES NO b declared bankrupt or the subject of bankruptcy proceedings? YES NO c the subject of a County Court Judgement (or Scottish equivalent)? YES NO d a director or partner in any business which has been the subject of an individual voluntary arrangement with creditors, voluntary liquidation, a winding up or administrative order, or administrative receivership proceedings? YES NO 3 Have you been in business in the name(s) shown under Proposers Details above for less than 3 years? YES NO If yes, please provide previous business history. IF YOU HAVE TICKED ANY OF THE SHADED BOXES, PLEASE GIVE DETAILS BELOW. PLEASE USE THIS PAGE TO GIVE FULL DETAILS IF YOU HAVE ANSWERED YES TO ANY OF GENERAL QUESTIONS 1 TO 3. NIG Traders Combined Proposal Form 3

6 SECTION 1 MATERIAL DAMAGE Please tick cover required: Commercial All Risks or Fire, Special Perils & Theft 1 Property to be insured Note 1 Note 2 All items below with the exception of Stock and Rent can be covered on a Day One basis.if this is required please tick the box below and indicate the % uplift required. The figure then entered under the 'sum insured' will be the Declared Value. The Declared Value should represent the full replacement cost of the property at the commencement of the Period of Insurance. If any of the Sums Insured apply to more than one premises, please give the appropriate split on a separate sheet. Note 3 Do not include the value of any items to be separately insured under Sections 10 and/or 14 The buildings of the premises (including landlords fixtures & fittings, outbuildings, walls, gates and fences) Tenants Improvements/Decorations for which you are responsible Plant, Machinery, Trade Fixtures, Fittings and All Other Contents except for Portable Hand Tools and Electronic Business Machines, Computers and Software Portable Hand Tools belonging to Proposer and/or Employees for which you are responsible (500 max value any one tool) Electronic Business Machines, Computers and Software Stock in Trade (except for that stated below) and customers goods Stock of Cigarettes and Tobacco Stock of Wines and Spirits Stock of Non-Ferrous Metal Day One % Uplift Sum Insured Stock at Exhibitions: Number per year Per exhibition Rent Years Sum Insured (total Rent) 2 Please state how the premises to be insured are occupied by you (e.g. factory, workshop, warehouse, offices) 3 Are the premises a built entirely of brick, stone or concrete and roofed with slates, tiles or concrete YES NO b heated by gas (but not liquefied petroleum gas) electricity or oil fired central heating YES NO c in a good state of repair with all machinery properly fenced or guarded and in good order YES NO d solely occupied by you YES NO If you have answered 'no' to any any of the above, please provide full details below 4 Are the premises specially exposed to damage by storm? YES NO 4 NIG Traders Combined Proposal Form

7 SECTION 1 MATERIAL DAMAGE - continued 5 Are the premises in an area susceptible to flooding? YES NO If 'yes' please provide details of any known improvements made/planned by the Environment Agency 6 If you require Subsidence, Ground Heave and Landslip cover on the Buildings, please state whether: a the premises have suffered or are showing signs of such damage YES NO b the properties either side of you have suffered or are now showing signs of this damage YES NO c to your knowledge the vicinity is susceptible to such damage YES NO d the premises are in the immediate vicinity of any river bank, railway embankment or cutting, cliff or quarry, mine or other underground working or on made up ground YES NO e there are any trees or shrubs over 20ft in height within 30ft of the premises YES NO If 'yes' to any of the above, please give full details 7 Do you require cover for Sprinkler Leakage? YES NO 8 Is an intruder alarm system installed at the premises? YES NO If 'yes' state a Name of Alarm Company b Is it maintained by the Alarm Company under contract YES NO c Method of signalling eg. Redcare, Redcare GSM, Paknet d Has police response been withdrawn or the level of response reduced or delayed? YES NO If yes please give details SECTION 2 BUSINESS INTERRUPTION Note: The Perils normally given under this Section will follow those provided under Section 1. Please state any variation required NIG Traders Combined Proposal Form 5

8 SECTION 2 BUSINESS INTERRUPTION - continued 1 Please insert the Sum Insured or Estimate required against the items to be insured bearing in mind the maximum indemnity period: Gross Profit Gross Revenue Gross Rentals Increase in Cost of Working Additional Increased Cost of Working Cost of Document Replacement 2 Outstanding Debit Balances (based on the maximum outstanding at any one time) 3 Indemnity Period required? 4 If Gross Profit or Gross Revenue is insured this policy includes a 25,000 limit in respect of the UK extensions mentioned below. Please insert any increases required a Unspecified Suppliers (maximum 10% of the sum insured or 500,000 whichever is the less) b c d e f Unspecified Customers (maximum 10% of the sum insured or 500,000 whichever is the less) Property stored Documents temporarily elsewhere Contract sites Premises of public utilities (electricity, gas, water, telecommunications) 5 Is cover required for business interruption caused by any of the perils insured at the premises of specific suppliers and/or customers? YES NO If 'yes' please state as a percentage the amount of Gross Profit that would be affected and the suppliers and/or customers name, address and description of business activities. i Supplier ii Customer 6 Please give details of any other extensions required ie. murder, suicide, food poisoning 7 State type of records kept of outstanding debit balances 8 Are they kept in a fire resisting safe, compartment or cabinet? YES NO 9 Are duplicate records kept? YES NO If 'yes' state where they are kept 6 NIG Traders Combined Proposal Form

9 SECTION 3 GOODS IN TRANSIT 1 State nature of goods carried 2 Do you engage in transit of goods outside the United Kingdom YES NO If 'yes' give details and countries regularly visited 3 For carriage of goods by your own vehicles state: a b c Maximum sum insured required per vehicle Maximum number of vehicles that will transport the goods Makes and types of vehicles used for carrying the goods d Are vehicles fitted with special locking devices, immobilisers and/or alarms? YES NO If 'yes' please give details e Maximum sum insured required for any one event ie. if more than one vehicle is left loaded for transit at any location at any time f Are any of the vehicles open or soft topped, or curtain sided? YES NO If 'yes' give details of vehicles *NB Storm Damage will be excluded. Also, theft or attempted theft from these types of vehicles will be excluded unless the vehicle is stolen at the same time 4 For carriage of goods by road haulage contractor, railway operator, post or inland air freight state: Maximum value any one consignment - own vehicles Maximum value any one consignment - third party carriers Estimated total annual carryings - own vehicles Estimated total annual carryings - third party carriers NIG Traders Combined Proposal Form 7

10 SECTION 4 LOSS OF BUSINESS MONEY If 'yes' please state Maximum Amount any one time 1 a in transit and/or in bank night safe b c on the premises during business hours on the premises outside business hours: i ii in a locked safe not in a locked safe Please give the following information about safes Make and Model Age (years) Anchored to Floor Limit required for Negotiable Money d e with travellers or collectors in private dwelling of proposer or authorised director/partner/employee 2 Estimated annual amount of money in transit (excluding crossed cheques and other non-negotiable currency) SECTION 5 PERSONAL ACCIDENT (ASSAULT) If 'yes' tick benefits required per person insured: 1 a 5,000 Capital Sums and 50 per week Temporary Total Disablement (25% of this for Temporary Partial Disablement) YES NO b 10,000 Capital Sums and 100 per week Temporary Total Disablement (25% of this for this for Temporary Partial Disablement) YES NO SECTION 6: EMPLOYERS LIABILITY SECTION 7: PUBLIC LIABILITY SECTION 8: PRODUCTS LIABILITY Is Insurance required? a Employers Liability (Indemnity Limit 10,000,000 inclusive of costs and expenses) YES NO b Public Liability YES NO c Products Liability YES NO 1 If Public/Products Liability is required please indicate the Indemnity Limit required: 1,000,000 2,000,000 5,000,000 2 Do you undertake work in or on any nuclear plant or power station, gas or chemical works or stores, oil refineries or bulk oil storage facilities, offshore installations, airports, ships docks and/or mines? YES NO If 'yes' please give full details below. Please note that cover for this work cannot be granted until confirmed by NIG. 8 NIG Traders Combined Proposal Form

11 SECTION 6: EMPLOYERS LIABILITY SECTION 7: PUBLIC LIABILITY SECTION 8: PRODUCTS LIABILITY - continued 3 Will you process, use, handle or store any of the following in connection with your business a Silica, asbestos or any substance containing asbestos YES NO b Radioactive substance(s) YES NO c Any other industrial materials that are toxic, explosive, flammable, corrosive or an irritant YES NO If 'yes' please give full details 4 Do you store liquids or gases in bulk? YES NO If 'yes' please give full details 5 Do you discharge toxic or dangerous substances into the atmosphere, sewers, waterways or elsewhere? YES NO If 'yes' please give full details, including method of treatment and disposal. Please note that cover for this work cannot be granted until confirmed by NIG. 6 Is all of your lifting plant and pressure vessels/boilers which are subject to Statutory Regulations regularly inspected by qualified engineers as required by the legislation? YES NO 7 a Do you comply with the requirements of the Factories Act, the Health and Safety at Work Act, and the Control of Substances Hazardous to Health Regulations (and any special regulations thereunder) or any similar legislation? YES NO b Have you or any of your Directors, Partners or Employees ever been:- i prosecuted under any of these Acts or Regulations YES NO ii served with a Prohibition Notice under the Health and Safety at Work Act YES NO If 'yes' please give details 8 Have you or, to your knowledge, any former owner or occupier of the site in respect of the premises at any time: a Been prosecuted or sued for any pollution problem YES NO b Had any incidents of pollution, or incidents likely to cause pollution YES NO c Carried on any industrial activity which was the subject of an environmental permit of licence YES NO If 'yes' please give details 9 a Do you carry out any work away from the Business premises? If 'yes' please give details NIG Traders Combined Proposal Form 9

12 SECTION 6: EMPLOYERS LIABILITY SECTION 7: PUBLIC LIABILITY SECTION 8: PRODUCTS LIABILITY - continued b Is any of this work outside of the United Kingdom? YES NO If 'yes' please state the Countries and what percentage of your total work this represents c Does any of your work away from the Business premises involve the use of: i welding or cutting equipment or other equipment involving the application of heat? YES NO ii cradles and/or other lifting equipment? YES NO If 'yes' please give details 10 Does any of your work produce noise level above 85dB(A)? YES NO If 'yes' please give details and state what precautions are taken 11 Have you entered into any agreement assuming liability for injury, illness, loss or damage for which you would not have been liable in the absence of such agreement? YES NO If 'yes' please supply a copy of the agreement 12 Where Bona-Fide Sub Contractors are used, do you check that they are insured for public/products liability? YES NO 13 Please state Estimated Annual Wages, Salaries and other Earnings as below: Note: Estimates should include all payments to Working Directors/Partners, Labour only Subcontractors, Self Employed Persons and people hired or borrowed and should be stated as Gross ie. Before deductions. A minimum of 15,000 per partner or director must be applied At the Premises Working Principal(s) (specify duties) Clerical/Secretarial/Administrative Employees using woodworking machinery power presses and guillotines All other Employees (specify duties) Work Away from the Premises Working Principal(s) (specify duties) Commercial Travellers/Salesmen All Other Employees (specify duties) Bona Fide Sub Contractors (specify duties) 14 Under Employers Liability do you wish to insure injuries to working partners YES NO Note: Many businesses must be registered with the Local Authority or with HSE for health and safety purposes. If you are in any doubt please consult your nearest HSE office (details in the telephone directory under 'Health and Safety Executive') 10 NIG Traders Combined Proposal Form

13 SECTION 6: EMPLOYERS LIABILITY SECTION 7: PUBLIC LIABILITY SECTION 8: PRODUCTS LIABILITY - continued If Section 8 Products Liability is requested, please answer the following questions (note - only available if Public Liability Insurance is also selected) 15 Describe types of Products manufactured, sold, supplied, repaired, serviced, tested, processed and/or purchased for resale (please provide catalogues or similar literature) 16 Please state: a Estimated annual turnover Goods manufactured by you Goods retailed/ wholesaled Goods repaired, processed, altered or treated b Percentage exported to: i U.S.A or Canada % % % ii European Union % % % iii elsewhere % % % 17 State actual turnover of exports to USA/Canada for the past 12 months N.B. For questions 16(b)(i) and 17 you should include any indirect exports i.e. goods that you know will ultimately be exported to USA/Canada even though they may not be exported directly by you. 18 In which overseas countries do you have offices, assets, representation or agents? 19 Do you import raw material, components or finished products? YES NO If 'yes' please provide:- Details of goods Countries involved % of annual turnover (i) European Union (ii) elsewhere (list countries) 20 Where goods or material are purchased by you or work is carried out on your behalf do you forgo under contract any right of action which may otherwise be available? YES NO If 'yes' please provide a copy of the contract wording(s) 21 Are any goods intended for installation in or to form part of aircraft, watercraft, drilling rigs, atomic or nuclear plant or motor vehicles? YES NO If 'yes' please give details including annual turnover of such goods 22 Which products are: a manufactured/supplied to your own design/specification/formulation? b manufactured/supplied to a design/specification/formulation laid down by your customers? NIG Traders Combined Proposal Form 11

14 SECTION 6: EMPLOYERS LIABILITY SECTION 7: PUBLIC LIABILITY SECTION 8: PRODUCTS LIABILITY - continued 23 Do you maintain an adequate system of records which would enable identification of: a the source of product/raw materials/component parts purchased? YES NO b the source of design of Products manufactured by you? YES NO 24 Is it possible to trace the ultimate customers of individual products or batches in order to recall the products? YES NO 25 Has recall ever been necessary or been considered? YES NO 26 Are all goods labelled and supplied with clear instructions in the language of the country to which they are supplied? YES NO 27 Are product-hazard warnings clearly shown on products, packaging and/or instruction manuals? YES NO 28 Have you or any Principal in the business ever been prosecuted or received notice of intended prosecution under the Consumer Protection Act, Food Safety Act or similar legislation? YES NO IF YOU HAVE PLACED A TICK IN ANY OF THE SHADED BOXES FOR QUESTIONS 23 TO 28, PLEASE PROVIDE FULL DETAILS BELOW SECTION 9 GLASS BREAKAGE Note: Where buildings are insured on an "All Risks" basis glass in the structure of the building is automatically included 1 Do you wish to insure all external and internal glass in the structure of the premises? YES NO 2 Do you wish to insure signs? YES NO If 'yes' please give details including the sum to be insured SECTION 10 ALL RISKS ON SPECIFIED MACHINERY/APPARATUS If 'yes' complete below details of items to be insured and the Geographical Limit to apply The options for Geographical Limits are: A B C D The Premises Anywhere in the United Kingdom, Channel Islands and Isle of Man (including the Premises) Europe which shall mean anywhere in the United Kingdom, Channel Islands and Isle of Man and the Countries of the European Union. Worldwide which means anywhere in the World including the United Kingdom and Europe Make and Type of plant/machinery Serial No Geographical Limit Sum Insured 12 NIG Traders Combined Proposal Form

15 SECTION 11 DETERIORATION OF REFRIGERATED FOODS If 'yes' state sum insured Maximum sum insured per cabinet Number of cabinets 1 Are any of the cabinets over 5 years old YES NO 2 If 'yes' is there a maintenance contract in force? YES NO SECTION 12 ENGINEERING DAMAGE TO MACHINERY & PLANT 1 Do you require inspection of any machinery and plant? YES NO If yes, please list the items below. 2 Do you require insurance for damage to machinery and plant? YES NO If yes, please tick which options you require: a Specified items (please list below) OR All machinery and plant b Explosion and breakdown cover OR Sudden and unforeseen damage cover NB If you select the all machinery and plant option but only some items require inspection please list those items Item Description Inspection Insurance Y/N Y/N SECTION 13 ENGINEERING BUSINESS INTERRUPTION 1 If 'yes' please indicate the Annual Gross Profit and the Maximum Indemnity Period Required months SECTION 14 COMPUTER INSURANCE 1 Please list the Equipment to be insured, its replacement cost and the Geographical Limit to apply NB The options for Geographical Limits are as under Section 10 Description of Equipment Geographical Replacement Limit Cost 2 Optional Business Interruption extensions are available. If either of these are required please indicate below and state the Sum Insured and Maximum Indemnity Period required Sum Insured Indemnity Period a Loss of information months b Increased Cost of Working months NIG Traders Combined Proposal Form 13

16 SECTION 15 LOSS OF LICENCE 1 Please state the maximum amount to cover this loss NB This should be the amounts of twelve months income and the depreciation from the normal value of the premises should the business consequently be disposed of. 2 Are you aware of any environmental, planning, compulsory purchase or similar local authority legislation likely to affect the future of your licence? YES NO 3 Is there any other matter of whatsoever nature pending which is likely to affect the future of the licence? YES NO If you have answered 'yes' to 2 or 3 please provide full details DATA PROTECTION AND DECLARATION Your Insurer You are giving your information to NIG who is a member of Royal Bank of Scotland Group (The Group). For information about our Group of companies please visit and click on About Us, or for similar enquiries please telephone or Textphone Your electronic information If you contact us electronically, we may collect your electronic identifier e.g. Internet protocol (IP) address or telephone number supplied by your service provider. How we use your information and who we share it with We will use your information to manage your insurance policy, including underwriting and claims handling. This may include disclosing it to other insurers, third party suppliers, loss adjusters and reinsurers. Your information includes data about your transactions. We may use and share your information with other members of the Group to help us, and them: assess financial and insurance risk, recover debt, prevent and detect crime, develop services and systems. We do not disclose your information to anyone outside of the Group except: where we have your permission; or where we are required or permitted to do so by law; or to other companies who provide a service to us or you; or where we may transfer rights and obligations under this agreement. We may transfer your information to other countries. If we do this we will ensure that anyone to whom we pass it provides an adequate level of protection. Credit reference agencies Your information may be linked to, and your application assessed using, credit reference agency records relating to anyone with whom you have a joint account or similar financial association. Fraud Prevention Agencies If false or inaccurate information is provided and fraud is identified or suspected, details may be passed to fraud prevention agencies. Law enforcement agencies may access and use this information. We and other organisations may also access and use this information to prevent fraud and money laundering for example when: checking applications for, and managing credit and other facilities and recovering debt; checking insurance proposals and claims; checking details of job applicants and employees. We, and other organisations that may access and use information recorded by fraud prevention agencies, may do so from other countries. We can provide the names and addresses of the agencies we use if you would like a copy of your information held by them. Please contact us at NIG, Crown House, 145 City Road, London EC1V 1LP. The agencies may charge a fee. 14 NIG Traders Combined Proposal Form

17 DATA PROTECTION AND DECLARATION - continued Further information If you would like a copy of the information we hold about you, please telephone and ask for a Subject Access Request Form. Alternatively, you may download a Subject Access Request Form from our Internet site at A fee may be payable. Declaration I/We declare that: a b c d e if any answer has been printed or written by any other person, he/she shall be my agent for that purpose. I also confirm that any data which I have supplied in this form about other persons is given with their knowledge and authorisation to the best of my/our knowledge and belief the information given in this form is correct and complete in every detail I/we agree that this Proposal and Declaration, and any additional information on the insurance provided by my/our insurance intermediary on my/our behalf to The National Insurance and Guarantee Corporation Ltd trading as NIG ( the Company ), shall be the basis of the contract between me/us and the Company I/we accept and conform to the terms, conditions and exceptions of the policy (a specimen of which is available on request) in the standard form issued by the Company for the Insurance now proposed and I will pay the premiums thereon. I/we consent to the information given in this form, any information we may obtain from Fraud prevention agencies or information received with any subsequent claim I/We may make being used in the manner set out under How we use your information and who we share it with above. Proposer s Signature Status Date NIG Traders Combined Proposal Form 15

18 ADDITIONAL INFORMATION FOR INTERNAL USE ONLY Proposal Checked by Date 16 NIG Traders Combined Proposal Form

19 NIG is the trading name of The National Insurance and Guarantee Corporation Limited. Registered in England & Wales number at Crown House, 145 City Road, London EC1V 1LP Authorised and regulated by the Financial Services Authority. Calls may be recorded.

20 Traders Combined NIG, Crown House, 145 City Road, London EC1V 1LP NIG2177G/05/08