Combined Liability Insurance Proposal Form

Transcription

1 Proposers details Combined Liability Insurance Proposal Form Salisbury House, 81 High Street, Potters Bar, Herts. EN6 5AS Tel: Fax: Full name of proposer... Correspondance address......postcode... Telephone number:... address:... Website:... Employer s reference number... Include details of ALL companies and subsidiaries to be insured Full description of trade/business... NOTE: Only the business shown above will be insured. Please make sure you describe ALL business activities. Number of years trading at these premises:...years Number of years trading at other premises:...years Period of insurance from... (dd/mm/yyyy) to...(dd/mm/yyyy) Sections required (Please tick) A. Employers liability B. Public liability C. Products liability Please complete parts: 1) all general questions; 2) sections where cover required; and 3) the declaration. General questions YES / NO If you tick any of the shaded boxes, please provide details under the Additional Information section (page 5/6). 1. Have you or any of your partners, principals or directors been insured or are you currently insured in respect of any of the insurances now proposed in this or any other name? If Yes, please give name of current insurer:... and expiring premium: Have you or any of your partners, principals or directors in relation to this business or any other business which you or they are currently involved in or have previously traded i) had any insurer decline, cancel or refuse to renew insurance or had any special terms, restrictions or conditions imposed by any insurer? ii) been prosecuted under the Health and Safety at Work Act or similar legislation, or have such a prosecution outstanding? iii) suffered any loss, damage, sickness or injury or incurred any liability in the last five years which has or could have given rise to a claim under any of the insurances now proposed whether or not insurance was in force? 3. Have you or any of your partners, principals or directors i) been declared bankrupt or been disqualified from being a company director or been involved as owner, director or partner with any company which went into receivership, administration or liquidation? ii) been the subject of (or have pending) any County Court judgements or Sheriff Court decrees? iii) been convicted or charged (or to be tried) or been given an official police caution in respect of any criminal offences? Page 1 of 6

2 General questions (contuinued) YES / NO 4. Are all lifts, cranes, hoists, rollers, steam containers and other pressure vessels inspected to comply with all statutory requirements? 5. Have you notified the local authority or Health & Safety Executive of your business at the address(es) covered by this insurance? 6. Do you comply with the Factories Act, the Health and Safety at Work Act, Manual Handling Regulations and all other appropriate Acts and Regulations? 7. Have you ever been prosecuted or served with a notice under such Acts or Regulations? 8. Is all plant and machinery properly fenced, guarded and maintained? 9. Are you accredited with any quality standard (e.g. ISO9000, BS5750) or similar? 10. Do you use heat equipment away from your own premises? Heat equipment means electro, oxy-acetylene or similar welding or cutting equipment, blow lamps, blow torches, hot air guns,strippers or asphalt, bitumen, tar or pitch heaters, carpet irons or aspirated irons. 11. Do you undertake work at high risk premises? High risk premises means power stations, nuclear installations or establishments, refineries, bulk storage or production premises in the oil, gas or chemical industries, computer rooms, railways and airports. It also includes work on computers (other than personal computers), aircraft, hovercraft, watercraft, aerospace systems underground or underwater. 12. Do you undertake manual work outside Great Britain, Northern Ireland, Channel Islands or the Isle of Man? 13. Do you undertake work at heights over five metres above ground level (or over five metres above floor level internally) or depths below two metres? 14. Do you, are you likely or have you ever undertaken any work or supplied any products for use in conjunction with any offshore industries (including any offshore accommodation, exploration, drilling or supply rig/installation or offshore supply vessel)? 15. Do you use, handle, store or transport any hazardous substances or discharge any hazardous substances into the atmosphere, sewers, waterways or elsewhere? (Hazardous substances means toxic chemicals, explosive substances, gases, asbestos, radioactive substances or any material giving rise to dust, fumes or vapours) 16. To the best of your knowledge have you ever used, handled, discharged, stored, transported or disposed of such hazardous substances in the past? 17. Does the operation of your business result, or has it resulted in the past, in any impairment of the environment e.g. disposal of liquids, gases or waste materials, fumes, vapours or excessive noise? 18. Does any part of your business undertake processes which may contribute towards any form of occupational or industrial disease? 19. Have any of your employees complained of any occupational or industrial disease e.g. deafness, repetitive strain injury? 20. Do you ensure that all sub-contractors have liability insurance with a limit of indemnity at least equal to yours? 21. Do you undertake any design work separately for a fee? 22. Do you hire out mechanically propelled plant? If YES, do you hire out under CPA Model Conditions or SPAO Contract Conditions? 23. Does any of your staff undertake work at home (including the use of Display Screen equipment/dse s)? If YES, have they been given training on how to undertake their own risk assessments? 24. When did you last carry out a Health and Safety Assessment? Date: Important note Failure to disclose all material facts (that is those facts an insurer would regard as likely to influence the assessment and acceptance of this proposal) could invalidate the insurance. If you have any doubt whether a fact is material you should disclose it. Page 2 of 6

3 Section A Employers Liability Please tick if you require this cover: Employers liability (Standard limit is 10 million) To help us identify our exposure to large accumulations of persons at any one location we need further information. If you have locations where the total number of your employees at any one time exceeds or may exceed 50 please provide information below. Name of employing company Location address including postcode Descriptionof location (e.g. factory, office etc.) Number of employees Annual wages/salaries estimate Please include payments to self employed persons, homeworkers, outworkers and persons supplied to you for study, work or training within wages and salaries. Wages and salaries should include overtime, value of board and lodgings, housing accommodation, bonuses and other payments in kind or money (including tips). No deduction should be made for National Insurance, income tax, holidays with pay, contributory pensions or payment under court orders. Adjustments. Your premium for the forthcoming period of insurance will be based on the estimates you provide. At the end of the period of insurance you will be required to declare the actual figures and pay any resultant additional premium accordingly. Woodworkers and those who at any time may use non-portable woodworking machines or portable power saws should be shown separately. Number of current employees on which estimated wages are based Wages/salaries and payments to employees Payments to labour only sub-contractors Payments to bonafide sub-contractors Managerial, clerical and other non manual (e.g. work performed without the need of physical effort) Woodworkers at the premises Manual work at the premises Manual work away from the premises Total estimate of all wages and salaries: proposed year previous year Page 3 of 6

4 Section B and C Public and Products Liability Please tick the cover you require: Public liability only Public and Products Liability (Standard limit is 1 million) If this is not adequate please state limit required... (The limit of indemnity applies to each and every insured event for public liability and to all insured events in total occurring during the period of insurance for products liability, pollution or contamination). Estimated annual turnover by territory Turnover should be as defined in the Companies Act, that is, excluding trade discounts, VAT, excise duty and other sales tax. Where there is any trading between your companies, show the total turnover after adding together the turnover figures of individual companies. Proposed year UK EU countries USA/Canada (including their dependent territories) Elsewhere Previous year Additional questions YES / NO If you tick any of the shaded boxes, please provide details under the Additional Information section. 1. What goods do you manufacture, sell, supply, repair, test or process? (please attach brochures if available) What do you construct, erect or install away from your premises? (please attach brochures if available) Do you alter any products (including packaging and instructions) that you do not manufacture? 4. Do you have any parent company, subsidiaries, office, agent or representation or hold any assets outside Great Britain, Northern Ireland, the Channel Isles or the Isle of Man? 5. Do you import products from outside the E.U.? 6. Do you arrange for the supply of products which are sent directly to your overseas customers from your overseas suppliers? 7. Do you release your suppliers from any of their responsibilities by agreement, contract or other means? 8. Are any products knowingly supplied or services rendered to the medical, nuclear, aviation, aerospace, motor, marine, rail, offshore, defence or petrochemical industries? 9. Do you undertake product testing before sale or maintain product control systems? 10. Do your products conform to an independent product standard? (e.g. the British Standard Institute mark) 11. Do you currently or have you at any time in the past 10 years knowingly supplied goods to the USA or Canada (or their dependent territories) either directly or indirectly? Page 4 of 6

5 Declaration We declare that we have read all the statements and particulars given, including those answers written for us by any other person and that to the best of our knowledge and belief, the contents of this proposal form, all attached additional information and other particulars which have been given separately to Incepta Risk Management Limited by ourselves or our agents are true and complete and that no material facts have been omitted, misrepresented or mis-stated. We agree that this proposal form, any additional information supplied and this declaration shall be the basis of the contract between us and Incepta Risk Management Limited and we undertake to pay the premium when asked to do so. We agree that Incepta Risk Management Limited may contact our previous insurers for further information and/or clarification if required. Important notice Failure to disclose material facts could result in your policy being invalidated. Material facts are those facts which might influence the acceptance or assessment of your proposal. If you are in any doubt as to whether a fact is material you should disclose it. Signed for and on behalf of the proposer by: Name... Position in company... Signature... Date... Choice of law There is a choice of law which can apply to the policy when accepted but this pre-contractual offer by us, subsequent acceptance by you and the contract itself have been made on the basis of English law and this can only be amended with the express written agreement of both parties to the contract. Complaints Any enquiry or complaint concerning this insurance should in the first instance be addressed to your broker and then Incepta Risk Management Limited. Complaints that cannot be resolved by them may be referred to the Financial Ombudsman Service. Further details will be provided at the appropriate time. Additional information Question number Page 5 of 6

6 Additional information Question number Additional Information attaching to and forming part of proposal form dated :... Signature... Date... If you have any questions regarding your application, please do not hesitate to contact Elaine Southwell on elaine. or Page 6 of 6