Proposal Form. Tradesmen. Commercial Division

Transcription

1 Proposal Form Tradesmen Commercial Division

2 Tradesmen Policy A Policy designed to meet the needs of smaller contractors with up to 10 persons (employees and labour only sub-contractors) working manually at any one time. 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 Tradesmen 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 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 facts 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 your broker or agent on your behalf will be the basis of the contract between us. NIG Tradesmen Proposal Form 1

3 FOR INTERNAL USE ONLY Agent Name Agency Code When completing this form, please tick the appropriate boxes and answer all questions in BLOCK CAPITALS 1 YOUR DETAILS Full Name of Proposer Trading Name or Title Company Registration Number Business Address (Postcode must be shown) Web Site Address Business Phone No. Trade or Business www. Post Code How many years have you been in this Trade or Business? How many years have you been Trading in your own name? List any subsidiary companies to be insured Describe all work undertaken or proposed for the future / / Period of Insurance Inception Date Renewal Date / / 2 GENERAL QUESTIONS 1 Have you or any partner/director in connection with your Business ever suffered any loss, damage, injury or disability or incurred any liability (whether insured or not) during the past 5 years in connection with any of the risks now proposed? YES NO If yes please give full details below. Date Type of Loss Brief Details Amount Paid or Outstanding 2 NIG Tradesmen Proposal Form

4 2 GENERAL QUESTIONS - continued 2 Are you now or have you previously been insured for any of the risks now proposed or any similar commercial risks? YES NO If yes please state name of Insurer, policy number and expiry date. 3 Have you or any partner/director in connection with your Business:- a had any proposal or insurance declined, cancelled, refused, or made subject to increased rates or special terms? YES NO b been convicted of arson or any offence involving dishonesty of any kind (e.g. fraud, theft, etc.)? YES NO c been prosecuted under any health and safety legislation during the last 5 years? YES NO 4 Have you or any director or partner or any Company of which any of you have been a director or any partnership of which any of you have been a partner been the subject of a County Court Judgement (or the Scottish equivalent) or been declared bankrupt or insolvent? YES NO If a County Court Judgement has been registered, please state details including date and amount. IF YOU HAVE TICKED ANY OF THE SHADED BOXES, PLEASE GIVE DETAILS ON ADDITIONAL INFORMATION PAGE NIG Tradesmen Proposal Form 3

5 3 RISK DETAILS 1 Do you undertake work:- a overseas? YES NO b on Nuclear Plant/Power Stations, Gas or Chemical Works, Oil Refineries/ Bulk Oil Storage Facilities, Offshore Structures, Airfields/Airports or Railway property?* YES NO 2 Does any part of your trade or business involve work in connection with:- a quarrying,tunnelling or mining? YES NO b piling, ground stabilisation, underpinning or dewatering? YES NO c towers, steeples or chimney shafts? YES NO d bridges, viaducts, flyovers or underpasses? YES NO e docks, harbours, piers or wharfs? YES NO f dams, reservoirs, lakes, rivers, water diversion, flood protection or sea defences? YES NO 3 Do you work on or have under your control Cranes, Hoists, Passenger Lifts or Escalators? YES NO 4 Do you handle or use any of the following in connection with the work to be insured:- a Cradles? YES NO b Radioactive Substances or Devices, Chemicals, Explosives or Gases? YES NO c Asbestos or Silica or other material involving a health or safety hazard? YES NO d Any other dangerous materials giving rise to dust, fumes or vapours? YES NO 5 Do you discharge toxic or dangerous substances into the atmosphere, sewers, waterways or elsewhere?* YES NO *If yes please note that cover for this work cannot be granted until confirmed by NIG 6 Have you in connection with sites which you have worked on OR in respect of your Premises (including to your knowledge any former owner or occupant of the Premises) a Ever been prosecuted or sued for any pollution problem? YES NO b Ever had any incidents of pollution or incidents likely to cause pollution? YES NO c Ever carried on any industrial activity which was the subject of an environmental permit or licence? YES NO 7 Do you (a) HIRE IN or (b) HIRE OUT any vehicles or plant? If yes please state:- HIRED IN HIRED OUT a b c Type of vehicle or plant Estimated annual hire charges for the coming year Which conditions of hire apply. 8 Do you carry out any processes involving a noise level exceeding 90 decibels? YES NO 9 Do you operate a foundry or forge? YES NO 10 Do you handle or use welding or cutting equipment or other equipment or processes involving the application of heat away from your premises? YES NO 11 Is your plant regularly maintained and inspected to comply with statutory regulations? YES NO IF YOU HAVE TICKED ANY OF THE SHADED BOXES, PLEASE GIVE DETAILS BELOW OR CONTINUE ON THE ADDITIONAL INFORMATION PAGE 4 NIG Tradesmen Proposal Form

6 4 PUBLIC LIABILITY (STANDARD) 1 Which Limit of Indemnity is required? 1,000,000 2,000,000 5,000,000* 2 NUMBER OF PERSONS WORKING MANUALLY: a b PROPRIETORS AND PARTNERS (if not a limited company) EMPLOYEES, WORKING DIRECTORS, LABOUR ONLY SUBCONTRACTORS (including persons supplied by them) AND TRAINEES. Limited companies should declare all persons working manually under this category. 3 NUMBER OF PERSONS doing clerical work *Not available for heating and ventilating engineers, painters and decorators undertaking work involving the use of heat, plumbers and slaters and tilers. 5 EMPLOYERS LIABILITY (OPTIONAL) - COVER IS ONLY AVAILABLE UNDER THIS SECTION IF PUBLIC LIABILITY IS SELECTED Do you wish to insure in respect of this Section?* YES NO If yes please answer the following questions. 1 Is power driven woodworking machinery other than portable tools used in the Business? YES NO If yes state number of persons using such machinery. 2 Do you wish to insure against Injuries to Working Partners? YES NO *Not available for Window Cleaners 6 TOOLS & EQUIPMENT (OPTIONAL) - COVER IS ONLY AVAILABLE UNDER THIS SECTION IF PUBLIC LIABILITY IS SELECTED Do you wish to insure in respect of this Section? YES NO (Premium is based on the total number of persons working manually) DECLARATION IMPORTANT NOTE You are reminded that it is essential you 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 it should be disclosed. Failure to disclose any material facts may invalidate your policy or may result in your policy not operating fully. Under the conditions of your policy, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. We may also respond to enquiries by the Police concerning your policy in the normal course of their investigations. Where it is necessary to administer your policy efficiently or to protect your interests, we may disclose the data you have supplied to other third parties such as solicitors, loss adjusters, loss assessors or other insurers. You should show this notice to anyone insured under the policy, about whom personal information has been supplied. Data Protection: the data supplied in this Form will only be used for the purposes of processing your policy of insurance, including underwriting, administration and handling any claim which may arise. The data supplied will not be passed to any other parties other than those, whom we have disclosed in this Form. It is important that the data you have supplied are kept up to date. You should therefore notify us promptly of any changes so that we may update our records. You are entitled upon the payment of an administration fee to inspect the data, which we are holding about you. If you wish to make such an inspection, you should telephone and ask for a Subject Access Request Form. Alternatively, you may download a Subject Access Request Form from our Internet site at DECLARATION I/We: a b c d e declare that to the best of my/our knowledge and belief the information given in this Form is correct and complete in every detail also understand that you may also process information which has been received from other insurers, financial institutions or industry databases concerning other incidents in which any person covered under the policy may have been involved agree that 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 are given with their knowledge and authorisation agree that this Proposal and Declaration, and the additional information on the insurance provided by my/our insurance intermediary on my/our behalf to The National Insurance and Guarantee Corporation Limited trading as NIG ( the Company ), shall be the basis of the contract between me/us and the Company also agree to accept a policy (a specimen of which is available on request) in the standard form issued by the Company for the insurance now proposed and to pay the premiums thereon. Proposer s Signature Status Date NIG Tradesmen Proposal Form 5

7 ADDITIONAL INFORMATION 6 NIG Tradesmen Proposal Form

8 ADDITIONAL INFORMATION NIG Tradesmen Proposal Form 7

9 ADDITIONAL INFORMATION FOR INTERNAL USE ONLY Proposal Checked by Date 8 NIG Tradesmen Proposal Form

10 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.

11 Tradesmen NIG, Crown House, 145 City Road, London EC1V 1LP 2178H/11/06