AGRICULTURE E-ENQUIRY RISK PRESENTATION FORM

Transcription

1 AGRICULTURE E-ENQUIRY RISK PRESENTATION FORM Please note there is a comments page at the end of the form for any additional information Date produced on Quote required by Intermediary details Intermediary Name Address Postcode Contact person Direct Telephone no (inc code) address Client Details Client Name Postal address Postcode Business description Year established Period of Insurance From: To: Additional Information Do you currently hold this business? Name of holding intermediary Name(s) of holding insurer(s) (If No, please give name of current intermediary) Targets Expiry premium Target premium LTU expiry date (if applicable) Background information Provide any other relevant information on the company 1

2 Claims experience 5 Year History details of any incidents which have or could have resulted in a claim, whether insured or not. Date Address where occurred Cover Type Paid Outstanding Details of incident Date Address where occurred Cover Type Paid Outstanding Details of incident Date Address where occurred Cover Type Paid Outstanding Details of incident Date Address where occurred Cover Type Paid Outstanding Details of incident Date Address where occurred Cover Type Paid Outstanding Details of incident Date Address where occurred Cover Type Paid Outstanding Details of incident 2

3 General details How long have you been in business: i) in these premises? ii) elsewhere? Have you, your Directors, Partners or family members involved with the business or any other business ever: had a proposal or insurance declined cancelled or refused? Details of declinature, cancellation or refusal had any renewal refused? Details of renewal refusal had any special terms or conditions imposed? Details of special terms and conditions been convicted or charged (but not yet tried) or been given an Official Police Caution, in respect of any criminal offence? Details of criminal offence or police caution been the subject of any County Court Judgements or Sheriff Court Decrees? Details of Judgements or Decrees been declared bankrupt or insolvent 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? Details of bankruptcy, insolvency, disqualification, receivership, administration or liquidation been involved in another company within 6 months before receivership/insolvency? Details of receivership/insolvency Any other material facts to disclose? Material fact details 3

4 Please give details of previous insurers in the last five years 4

5 COVER REQUIRED Please specify covers required Asset Protection Farm Property Damage Livestock Supplementary All Risks Farm Property in Transit Money and Assault Frozen Foods Uncollected Milk Engineering Farm Home Farm Motor Revenue Protection Business Interruption Legal Liabilities Employers Liability Public and Products Liability Commercial Legal Protection Pollution Questionnaire Employee Benefits Personal Accident 5

6 ASSET PROTECTION FARM PROPERTY DAMAGE (Note if there is more than one premises you will need to fill in additional farm property damage sections) Address of main farm Postcode Type of farm Farm buildings Please list each building, or range of communicating buildings, with full use and construction details. Please indicate if any buildings are Listed Buildings. There are two basis of settlement (I) Indemnity or (M) Modern Materials, please specify below. Buildings Sum Insured Basis of settlement Please provide details of any local authority requirements applying to any of the above buildings Standard Contingencies are: Fire, Explosion, Aircraft, Riot (including Malicious Damage), Earthquake, Subterranean Fire, Spontaneous Combustion, Impact (excluding own vehicles or animals), Escape of Oil, Falling Trees. Do you require cover for Impact caused by your own vehicles or animals? Do you require cover for Storm or Tempest? Do you require cover for Storm, Tempest or Flood? Do you require cover for Escape of Water? Cover is subject to the suitability of your buildings and a survey may be required prior to cover. Farm property - There are two bases of settlement for certain items (I) Indemnity or (R) Reinstatement, please specify below. Where not specified, cover will be on an indemnity basis. Agriculture Produce* including growing crops and farming stock other than livestock Permanently fixed machinery and plant including attached accessories Machinery, plant and implements, including power driven vehicles and implements and their accessories Fixed milk plant Appliances for the hatching and rearing of poultry by artificial heat Tenants improvements, alterations and decorations Boundary walls, fences, hedges and gates. First loss Basis: Silage Hay and/or Straw Roots and Potatoes stored in a building Roots and Potatoes stored in the open Grain in detached buildings used solely for drying, dressing and/or storage of grain Grain in detached building Growing Timber (I) or (R) Sum Insured 6

7 Other please specify full details * Does the Agriculture Produce item include the value of crops for sale? Contingencies (please specify) Fire Explosion Aircraft Riot (including Malicious Damage) Earthquake Subterranean Fire Spontaneous Combustion Impact (excluding own vehicles or animals) Escape of Oil Falling trees Do you require cover for Impact caused by your own vehicles or animals? Do you require cover for Theft? Is terrorism cover required? General Are the buildings, fixed machinery and fences in a good state of repair? If No, give details Are the premises in an area previously affected by flooding or at risk of flooding? If Yes, give details Is the building located: Near a cliff or other exposed area Near a watercourse, canal or dam If Yes to any of the above, give details Near a lake, reservoir or dam Any portion of the premises partly unused/unfurnished/unoccupied? If Yes, give details Current Property Damage Excess Property Damage Excess for Quote Current Theft Excess Theft Excess for Quote 7

8 LIVESTOCK Description Sum Insured Transit Max number any one load Max value any one load Cattle Sheep Pigs Poultry Horses Goats Other (please specify) Do the above Sums Insured include the value of Livestock for sale? (Please note that if you have selected Business Interruption you do not need to include value of Livestock for sale) Do you wish to remove any of the following contingencies from this cover. Fire, Lightning and Explosion Aircraft Riot (including malicious damage) Third Party Impact Falling Trees Earthquake Do you require cover for: Impact caused by your own vehicles or animals Sheep worrying by dogs Sheep worrying by dogs and foxes Fatal injury to livestock** Electrocution Theft* Transit*** Cover will apply on the farm and any other farming premises or land occupied or used by you in connection with the business, unless otherwise stated. * On the farm or elsewhere as agreed. ** Elsewhere other than in transit or on farms or land occupied or used by you in connection with the business. *** Anywhere within Great Britain, Northern Ireland, the Channel Islands and the Isle of Man. 8

9 SUPPLEMENTARY ALL RISKS Property to be insured For each Item please specify the location that applies: Premises only The premises specified in the property damage section UK Anywhere in the UK including transit European Union Anywhere in the UK including transit and whilst temporarily removed anywhere within the European Union for up to 90 consecutive days Worldwide Anywhere in the UK including transit and whilst temporarily removed anywhere in the world for up to 90 consecutive days Limit any one item Sum Insured Fixed office equipment and installations Portable office equipment (excl computers and word processors) Computers and word processors Computer systems records Computer system records including the cost of reinstatement of information Cash registers, weighing machines, bacon slicers and similar shop equipment Portable Hand Tools Employees Personal Belongings ( 500 max per person) Mobile telephone and communication equipment Medical and vetinary equipment Frozen animal semen, artificial insemination straws, flasks and containers Other give details 9

10 FARM PROPERTY IN TRANSIT Specified own vehicle basis of cover Specified Vehicles if specified vehicle selected complete for each vehicle Vehicle make Vehicle type Reg No Vehicle security features Security device accreditation Single vehicle limit Sum insured for Tools per vehicle Unspecified vehicles and other carriage basis of cover Please select type of carryings using the tick box(es) plus indicate each carrying as a percentage of the total under split Carryings type Split Own private vehicles % Own commercial vehicles % Road % Rail % Post % Other (please state) % Limit any one consignment Limit any one occurrence Estimated annual value in transit Sum insured for Tools per vehicle Sum Insured 10

11 MONEY AND ASSAULT Money Stamped national insurance cards, crossed cheques, crossed giro cheques, crossed money orders, crossed postal orders, crossed bankers drafts, crossed warrants, national savings certificates, premium savings bonds, franking machine impressions, credit company sales vouchers and VAT invoices: 250,000 Estimated own annual carryings How often is money banked? How many people accompany each transit? Money at Home Money at home of authorised persons Money in safe out of business hours Type of safe Limit of cash in safe Money on the premises, during business hours Money outside safe, out of business hours Any other loss of money Assault Cover required? Standard amount cover 10,000 (for death, total and permanent loss of sight in one or both eyes, loss of one or more limbs, any other total and permanent disablement which, after 24 months of Bodily Injury, prevents the Insured Person from pursuing any occupation)/ 100 per week (total disablement within 24 months)/ 50 per week (partial disablement within 24 months) FROZEN FOODS Is maintenance agreement in force? If No, do the units have airtight sealed motors and compressors? Description of unit Year of manufacture Sum Insured UNCOLLECTED MILK Please advise: The maximum number of cows producing marketable milk at any time during the year The maximum number of days compensations is required Please select: The amount of compensation required per cow per day: Please select: The name of the company or organisation to whom you are contracted to supply milk: 11

12 ENGINEERING Location of Plant (if different from the Premises) Postcode Cover options (please specify): Sudden and Unforeseen Accidental Damage Breakdown, Explosion or Collapse Specified basis Description of Plant and Machinery New replacement value *Size of capacity Inspection service * Please insert dimension, BTU, HP, KW, safe working load etc as appropriate Indemnity limit: Is cover required for bulk milk storage tanks? Item Maker s name and number Date of Make Limit of Indemnity Sudden and unforeseen damage of plant Deterioration of milk Item 1 Item 2 Item 3 12

13 Are you aware of any defects in the Plant and Machinery being proposed? If yes to either of the above, please give full details. Do you have any maintenance or service arrangements with other firms in respect of the plant and machinery proposed? If Yes, give details. If No please give details of any preventative maintenance arrangements. 13

14 FARM HOME Client Name (if different) Ages Address of Property Postcode Is the Home for which insurance is required: Built of brick, stone or concrete with slate, tile, asphalt, metal or concrete roof? Self-contained, having its own separate lockable front door Occupied solely by you and your family as a permanent residence Used as a private residence and/or to administer the business of the farm and not for any other business In a good state of repair, and will this be maintained If NO has been answered to any, please provide full details. Is the home (please select) Detached semi-detached terraced other Owner occupied rented furnished rented unfurnished other Please describe other When was the home built? Number of bedrooms Has the home for which insurance is required ever been damaged by flood, subsidence, heave or landslip? To the best of our knowledge is there any history of flood, subsidence, heave or landslip in the area? Is the Home for which insurance is required: Occupied as a holiday home Regularly unoccupied throughout the day or night Ever left unoccupied in excess of 30 days If YES to any of the above, please provide full details Buildings Do you require buildings insurance? Enter the amount to be insured (Minimum amount 35,000) Pick type of cover required Where the property is built of stone, in the event of loss or damage do you wish to insure on the basis of rebuilding or repair in modern materials? Do you wish to accept a Voluntary excess for a discounted premium? Other Are you the sole owner of the building to be insured? Please state the name and address of other interested parties (eg Mortgagee/other owner) 14

15 Contents Do you require contents insurance? What cover do you require? Complete if Standard cover is selected Total Contents Sum Insured Do High Risk Items exceed one third of your Contents Sum insured? If Yes, advise amount required for High Risk Items Do you require the Personal Possessions Extension? (only available if Contents is taken out) Unspecified items sum insured (Show details below for any pedal cycle over 200 and personal possessions over A valuation is required where replacement value is more than 1000 for jewellery and watches) Specified Items Description Replacement Value Complete if Wider cover is selected Total Contents Sum Insured Does the total replacement value of all High Risk Items exceed one third of your Contents Sum Insured? If Yes please advise the Sum Insured for High Risk Items Personal Possessions Extension - complete if required Specified Items - A valuation is required where replacement value is more than 1000 for jewellery and watches Description Replacement Value Extensions to Contents Insurance (Only available where Contents cover is selected) Do you wish to insure: (a) For Family Legal Protection (b) Your Caravan(s)/Mobile Home(s) Make and Model Type (static or tourer) Year of Make Date of Purchase Price Paid Estimated current value (b) Your Caravan(s)/Mobile Home(s) Type and Breed Name/Number Date of Birth Sex and Colour Price Paid and Date of Purchase Replacement Cost Do you wish to accept a Voluntary excess for a discounted premium? Other Tenants Improvements Sum Insured (if required) Security details (please provide full details of alarm company etc) Do you currently hold No Claims Bonus for you household insurance? If Yes, how many years claim free does this represent? 15

16 FARM MOTOR Specification of vehicles, please provide details overleaf. If any Agricultural vehicle is registered under the Limited Use Class of the Vehicle Excise and Registration Act 1994, please specify the registration mark/id numbers below Do you require attached trailer cover for attachments exceeding 10,000? Manufacturer Type of Trailer or Attachment ID Number Year of Manufacture Estimated Present Value Do you require Detached Trailer Cover? Total value of trailers Total number Maximum value any one trailer Cover required: Fire and Theft Accidental Damage, Fire and Theft Will any vehicle to be insured, be used for any purpose other than farming? If yes, provide details: Reg. Mark/ID No: Business/Details of Use: Drivers: Temporary Replacement vehicle cover? (Only available for Car or Goods Carrying Vehicles up to 7.5 tonnes GVW) (only available if comprehensive cover has been taken out) List vehicle registration numbers Do you require Uninsured Loss Recovery? Please list all drivers under the age of 25 (if any) and state the registration mark of the vehicle this person will drive Full Name of Driver Age DOB Full or Provisional Licence Licence - Yrs Held Job Title Registration Mark Do you wish to restrict driving to 1 or 2 persons over 25 years old? If Yes, please provide details Full Name of Driver Age DOB Full or Provisional Licence Licence - Yrs Held Job Title Registration Mark Have you, the Proposer or any Partner or Director (whether or not they currently drive) or any other person who will drive: ever had motor insurance cancelled or refused? been asked to pay an increased premium (other than normal rating increases) or had special conditions imposed? been convicted of or fined for any motoring offence (including fixed penalty offences) during the last 5 years or is any prosecution or Police enquiry pending? any physical or mental defect or infirmity or suffered from diabetes, fits or any heart complaint? lived permanently outside the UK or Republic of Ireland during the last 3 years? 16

17 If Yes, please provide full details including full name of driver, age, licence details, job title, DOB, Licence: Years held. Is any Vehicle owned by anyone other than you? If Yes, state registration mark/identification number of vehicle and name and address of owner Do you own any other vehicles which are not listed overleaf? If Yes, provide details including names of current insurers Have you, or any Partner or Director (whether or not they currently drive) or any other person who will drive, had a motoring accident and/or claim during the last 5 years? If Yes, please provide details: Full name of driver Date Details of Accident Cost of Claims Paid Outstanding 17

18 Schedule of vehicles Manufacturer, Model and Type of body Gross Vehicle Weight in tonnes Cubic Capacity Cover Year of Manufacture Present estimated value Date of purchase Registration mark or identification number No. of passenger seats No. of claim free years at this renewal 18 C: Comprehensive F: Third Party Fire and Theft T: Third Party Only

19 REVENUE PROTECTION BUSINESS INTERRUPTION Premises address Postcode Contingencies do these follow Property Damage and Livestock? If no, please specify cover required: Indemnity Period Other months Basis of Cover Other (Note: Declaration Linked liability is limited to 133.1/3% of the declared estimated amount. Estimated amount or Sum insured Revenue earned during your last financial year End date of your last financial year. Extensions please tick those required and indicate % or limit Specified Customers % limit (please provide details) Specified Customers % limit (please provide details) Gas Water Business Continuity Plan? Is terrorism cover required? % limit % limit Electricity If Yes, please provide a copy 19

20 LEGAL LIABILITIES GENERAL Name the current liability insurers and the length of time insured with them Please specify any accreditations for quality management (ie: ISO9000 series) Please specify any accreditations for environmental management (ie: ISO9000 series) Please specify any accreditations for other aspects of your business (ie: IIP) Safety policy Is there a safety policy What is the date of the last review of the safety policy When was it last communicated to all employees If there are more than 5 employees, is the policy in writing and signed No Knowledge of health & safety Is there a safety officer, or person responsible for health and safety issues If Yes, give details of formal training given to the person, If No, give details of external advice you obtain Risk assessment Have all the required risk assessments been carried out and recorded When was the last risk assessment carried out Training Please give details of what the health and safety training is given to employees Is training recorded Workplace inspections Is there a system for the inspection of all parts of the workplace on a regular basis in order to identify defects and hazards and to ensure any corrective actions is taken How often are inspections carried out? 20

21 EMPLOYERS LIABILITY Indemnity limit Number of EL Certificates Please give details of any industrial deafness, disease or contamination claims in the last ten years Employee wage breakdown Description Wageroll No of Employees Clerical and Non-Manual Farm Labouring All other wages (describe duties below) Proprietors/Partners wage breakdown Type of work Wageroll No of People Total Actual wages paid to employees during your last financial year Do you wish to cover your responsibilities under Agricultural Wages Board Orders? 21

22 PUBLIC AND PRODUCTS LIABILITY Public Liability Indemnity limit Estimated annual wages, salaries and other earnings Estimated annual turnover for the coming year Estimated payments to Independent Contractors Total area farmed (in Hectares) Do you at any time burn straw or stubble? If YES, do you comply with the Local Authority regulations which apply? If you employ Independent Contractors, do you check that they have Liability Insurance with an Indemnity Limit at least as high as the one you have selected? Do you export any product to overseas customers? If YES please provide details below Countries Products Turnover Do you engage in any of the following activities? If Yes, please state the estimated annual turnover from such activity Activity Turnover Retail sales, eg vegetables, milk, bread, honey etc. sold from a farm shop Provision of Accommodation for paying guests Letting of any land for caravan or tenting accommodation Crop Spraying for other farms Other Agricultural Contracting (please give details) Any other non-farming activity not specified above eg. Food Processing (please give full details) 22

23 COMMERCIAL LEGAL PROTECTION Standard cover includes Employment Disputes, Legal Defence, Property/Personal Injury and Inland Revenue and VAT Tribunals. Standard Cover only Optional Extensions (please tick) Contract Disputes Cover or Contract Disputes and Tenancy Disputes Cover Limit of Indemnity 100,000 Total estimated wages and payments made to employees Is work undertaken away from the premises? If Yes, please give details Has there been any legal dispute, action, prosecution, Customs and Excise or Inland Revenue investigations during the last five years? If Yes, please give details Are any redundancies envisaged in your business in the next 12 months? If Yes, please give details Have you been taken over, merged with or taken over any other company, or is it likely that your firm will do so with another company within the next 12 months? If Yes, please give details Additional Information 23

24 POLLUTION QUESTIONNAIRE Is there a river or major watercourse flowing through or marking the boundary of your farm? Has your farm ever been visited by any official water authority? If yes When was the last visit? What was the reason? Was any action required? No If so what was it? Have you complied? If you have undertaken a pollution appraisal, have you implemented its recommendations? (please provide a copy) If yes, have you complied with its recommendations? Do you have a Farm Waste Management Plan prepared or checked by a qualified Consultant? Are you certified to an Environmental Management System standard (e.g. ISO 14001)? If yes, do you have a documented environmental statement or management system (certified or not) Please attach a copy. What area of land relates to: Arable Grassland Other Does any of your land CURRENTLY consist of a Quarry, Dam, Infill or Waste Disposal (other than livestock waste) site? If yes Please provide details Has the site been licensed by the local authority? Has any part of your land PREVIOUSLY been used for Waste Disposal (other than livestock waste)? If yes Please provide details (list any known pollutants) Is any of your land used for non farming activities likely to give rise to a nonagricultural pollution claim? If yes Please provide details Maximum number of animals that can be housed on the farm Dairy cattle Beef cattle Pigs (breeding & fattening) How do you store/dispose of Manure, Slurry and Dirty water? How far is your storage/housing facility from the nearest watercourse, spring or borehole? How many tons of silage do you make each year? In silage clamps In bagged or wrapped bales In Ag-Bags or similar non-baled system Do the storage pads have impermeable bases and/or gullies to collect run off for storage and alter disposal? Do silage clamps have gullies to collect effluent and transfer to a tank? Do your Ag-bag sites for grass silage have impermeable base and gullies to collect effluent and transfer it to a tank? Do you store in above ground tanks? Are the tanks bunded? How far is/are the tanks from the nearest watercourse, spring or borehole? Sheep Dipping Is dipping carried out by Your employees? A mobile contractor? Is protective clothing issued and used? 24

25 Have all employees been trained in the proper use and disposal of organophosphate dips? If yes, how is surplus dip disposed of? Please provide details Have any claims been made in connection with sheep dipping in the last 5 years? Fuel Oil Fertilizer Do you store the following in above ground tanks? Are the tanks outlets locked? Are the tanks bunded? How far are the tanks from the nearest watercourse? Have you ever been convicted of an offence under The control of pollution act 1974? The environmental protection act 1990? Have you ever been convicted of an offence under The control of pollution regulations 1991? Date Details of incident Complaint Payment made Have you ever been issued with a Statutory Notice by an enforcing authority regarding pollution originating from your farm? If yes, please provide details Have you ever been prosecuted or sued for any pollution originating from your farm? If yes, please provide details Have any incidents occurred on your farm, which are likely to cause pollution or Contamination? If yes, please provide details Provide details of any previous incidents of pollution originating on your farm in the last 5 years 25

26 EMPLOYEE BENEFITS PERSONAL ACCIDENT Has any person now proposed suffered any accident (other than trivial) or any serious illness over the last five years? If Yes, please give details (Cover is only available for persons between the ages of 16 and 65 years at entry, in good health, bodily and mentally, and free from physical defect or infirmity) Contingencies 1. Death occurring within 24 calendar months of Bodily Injury 2. Total and irrecoverable loss of sight in one or both eyes within 24 calendar months of Bodily Injury 3. Loss of one or more limbs within 24 calendar months of Bodily Injury 4. Any other permanent and total disablement which lasts without interruption for more than 104 weeks from the date of Bodily Injury and prevents an Insured Person from following, engaging in or giving attention to usual profession or occupation 5. Temporary total disablement which prevents an Insured Person from engaging in or giving attention to usual profession or occupation commencing within 24 calendar months of Bodily Injury 6. Partial disablement which prevents an Insured Person from engaging in or giving attention to a substantial part of usual profession or occupation commencing within 24 calendar months of Bodily Injury Proprietors, partners or named employees Standard unit of cover: Contingencies 1, 2, 3 and 4 10,000 Contingency per week Contingency 6 50 per week Name Date of birth Contingencies (please specify) % of Standard Duties Name Date of birth Contingencies (please specify) % of Standard Duties Name Date of birth Contingencies (please specify) % of Standard Duties Name Date of birth Contingencies (please specify) % of Standard Duties Name Date of birth Contingencies (please specify) % of Standard Duties Name Date of birth Contingencies (please specify) % of Standard Duties

27 Unnamed Employees Standard basis of cover: Contingencies 1, 2, 3 and 4 Annual wage Contingency 5 Weekly wage Contingency 6 50% of weekly wage Contingencies (please specify) Cover restricted to accidents of occupation only Maximum Number Clerical Staff/Managerial (Non Manual Labour) Woodworking Machinists Supervisory and Occasional Manual Work Manual Work Est Annual Wages, Salaries and Other Earnings ADDITIONAL INFORMATION Please use this page for any additional information. Aviva Insurance Limited Registered in Scotland No 2116 Registered Office Pitheavlis Perth Scotland PH2 0NH Insurance P O Box 6 Surrey Street Norwich NR1 3NS Authorised and regulated by the Financial Services Authority BCOAR