Liability Insurance. Proposal Form For

Transcription

1 Liability Insurance Proposal Form For Mobile & Outside Caterers (and certain other catering & fringe risks) Insured by Zenith Insurance plc and/or its co-insurer QIC Insurance Limited Arranged by Hayden House Waterfall Lane Cradley Heath West Midlands B64 6PU Tel: Website: Mobilers Insurance Services are trading names of Insurance Factory Limited Authorised and regulated by the Financial Conduct Authority [306164] Registered in England and Wales [ ] Registered Office: Markerstudy House, 45 Westerham Road, Bessels Green, Sevenoaks, Kent, TN13 2QB

2 SECTION A: GENERAL DETAILS Full Name(s) Trading Name Correspondence Address Post Code Telephone Number (Home) Telephone Number (Business) Date of Birth Effective Date of Insurance Policy Term 1 day 3 days 12 months Do you fully understand that you cannot cancel or transfer this policy and that there is no refund of premium? Please describe fully the nature of your business Are you responsible for any seating arrangement? If YES, please state seating capacity & above If 101 and above please state seating capacity Are you involved in the erection or dismantling of any Marquee/Tent above 3.48m (10ft) in height? Have you registered your Business with the relevant Local Authority Environmental Health Department? If NO please give full details Are you responsible for Fixtures & Fittings? Are the premises rented? Have all gas installations been fitted by a Gas Safety Engineer? Do you have an up to date accident, risk assessment and training record? Are you an Ice Cream Alliance member? Are you a Retail Concessions client? Do you require Product Liability? Do you trade from a Wooden Pier?

3 SECTION B: COVER REQUIRED Please tick the box confirming your GROSS Annual Turnover: (NOT exceeding) 30, , ,000 60, ,000 Over 250,000 80, ,000 If over 250,000; please state Gross Annual Turnover If over 250,000 please state Annual Wage Roll How many people do you employ including part-time and casual? & above If NO employees, please tick here If 21 and above please state total number Your ERN Number SECTION C: HISTORY 1. Are you now or have you previously been insured for any of the risks now proposed? If YES, please state name of Insurer, policy number and expiry date 2. Do you have any liability policies in force on any other business? If YES, please give details 3. Have you or any partner/director in connections with your business suffered any claims or been involved with any incidents which may give rise to liability claim (whether insured or not), during the past 5 years for the risks now proposed? If YES, please give details including Date, Type of Loss and Amount Paid/Outstanding 4. Have <you/the policyholder>, any partner or director in connection with <your/the policyholder s> business ever: a. Had any proposal or insurance declined, cancelled, voided, refused, or made subject to increased rates or special terms? b. Been convicted of arson or any other offence involving dishonesty of any kind? e.g. fraud, theft, etc

4 c. Been prosecuted under any safety legislation during the last 5 years? d. Been declared bankrupt or insolvent? e. Been involved with a business which has ever been declared bankrupt or insolvent If YES to any question, please include FULL details 5. Has the proposer or any/partner/director ever had a Country Court Judgement registered against them? If YES, Please give details including date(s) and amount(s) SUMMARY OF COVER Public Liability: Products Liability: 5,000,000 ( 5 Million*) 5,000,000 ( 5 Million*) (inc. Food Poisoning) *Increasing to 10 million as and when required Employers Liability: Policy Excess* 10,000,000 ( 10 Million) The amount you are liable to pay should anyone make a valid claim against you for property damage, NOT personal injury.

5 SECTION D: DECLARATION IMPORTANT NOTE You are reminded that 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 it should be disclosed below. Failure to disclose all material facts may invalidate your Policy or may result in your policy not operating fully. I DECLARE that statements made by me in ANY PART of this Proposal to the best of my knowledge and believe are true and complete and if any answer has been given by any other person that person shall be deemed to be my agent for the purpose. Also I have not omitted any material facts and agree that this Proposal and Declaration shall be the basis of the contract between me and the Company and to accept a Policy (a specimen of which is available upon request) in the form issued by the Company for the Insurance now proposed and to pay the premium there on. SIGNATURE: DATE: PLEASE ENTER ANY ADDITIONAL INFORMATION AND MATERIAL FACTS BELOW IMPORTANT! All premiums quoted are minimum and retained premiums. There is no provision for cancellation of policies other than by Insurers and no refund of premiums allowed.

6 Underwritten by Zenith Insurance Plc and /or its co-insurers whose names and addresses are available on request. Zenith Insurance Plc is regulated by the Gibraltar Financial Services Commission and subject to a limited regulation by the Financial Conduct Authority and the Prudential Regulation Authority in respect of underwriting business in the UK (No ) Europort, Gibraltar. QIC Europe Limited is authorised and regulated by the Malta Financial Services Authority (MFSA) to carry on general Insurance business in terms of the Malta Insurance Business Act 1998 and subject to limited regulation by the UK Financial Conduct Authority and the Prudential Regulation Authority in respect of underwriting business in the UK (No ) No. 7m 4th Floor, Block c, Skyway Offices, 179 Marina Street, Pieta, PTA 9042, Malta. Several Liabilities Notice The obligations of Zenith Insurance Pie and it's co-insurers under contracts of insurance to which they subscribe are several and not joint and are limited solely to the extent of each insurers individual subscription. If one of the insurer does not for any reason satisfy all or part of its obligations the other insurer's will not be responsible for the defaulting insurer's obligations.