Proposal / Statement of Fact LOGISTICS: Haulage Contractors/Warehousing/Freight Forwarding/Couriers

Transcription

1 Proposal / Statement of Fact LOGISTICS: Haulage Contractors/Warehousing/Freight Forwarding/Couriers PLEASE COMPLETE IN BLOCK CAPITALS AND TICK APPROPRIATE BOXES WHERE RELEVANT If supplementary information is required please use supplementary form(s). Quotation Reference: PROPOSER S NAME: TRADING TITLE: FULL BUSINESS DESCRIPTION. POSTAL ADDRESS 2. Date cover to commence: / / / 3. Date commenced trading: at these premises / / / Elsewhere / / / 4. Details of all Directors, Partners, Financially Associated Persons: (a) NAME POSITION (b) (c) 5. Have you and/or any Director/Partner/financially associated person(s) ever been: (i) involved in any company that has become Insolvent and/or gone into liquidation? (ii) subject to a County Court Judgment? (iii) convicted of any crime? (iv) prosecuted under the Health & Safety at Work Act, Food Safety Acts, Data Protection Act, Environmental Protection Act or any Statute or Regulation YES NO (v) Has the Business changed name. If YES please supply detail? YES NO

2 If YES to any of the above please give FULL details 6. Please provide the name of your previous Insurers: 7. Has any previous Insurer: (a) declined your proposal? YES NO (b) cancelled or refused to renew your insurance or required an increased premium or imposed special terms? YES NO 8. Has the business had a change of Director/Partner/financially associated person(s)?... YES NO If Yes, please state when change occurred: If YES to any of the above please give FULL details / / 9. Is the Business VAT Registered? YES NO 10. If property is let to tenants, can you confirm if a tenancy agreement is in force? YES NO 11. Please give details of all claims made by you/a director/partner/financially associated person(s) have made during the last 5 years: Date of Loss Claim Details Settled Yes/No Settlement Amount Reserve Amount (if Not Settled)

3 Note: For additional properties please use Commercial Combined additional properties sheet. SECTION 1: BUILDINGS & CONTENTS COVER REQUIRED: YES NO RISK ADDRESS OF PROPERTY TO BE INSURED Address Line 1: Address Line 2: Address Line 3: Address Line 4: Address Line 5: Sums Insured Buildings : Or Tenants Improvements (only applicable if you do not own the building): Contents, Fixtures & Fittings Computers Electrical Office Equipment Own Stock in Trade for Maintenance & Repairs Machinery & Plant *(Please note that certain items of plant including lifts and cranes, pressure, electrical, power press or local exhaust ventilation (LEV) systems may be subject to Statutory Inspection requirements for which a separate engineering insurance policy should be arranged) Stock of Diesel Any other Property/Miscellaneous (please specify below) Any Interested Party in the Premises? YES NO If Yes, please state name & address:

4 Are all the buildings Standard Construction? YES NO (built of block, brick, stone, concrete, steel & roofed with slates, tiles, cladding, asphalt) If No, please provide details: Are any of the premises listed or have a preservation order attaching? YES NO If Yes, please provide details: Are any of the premises situated in an area prone to flooding, YES NO near a River, Stream, Reservoir or Lake? If Yes please provide details: Subsidence, Landslip and Heave Have any of the premises ever shown signs of damage which may be attributable to Subsidence, Landslip or Heave? YES NO If Yes, please provide details: Please outline heating type at the premises: Age or Building(s): Year Renovation Number of work carried out: Storeys: If Renovation work has been carried out, please provide details:

5 Are the buildings occupied by any other tenant or business other than yours? YES NO If Yes please provide details: Security Details Please provide details of all physical security, except alarm details: Is the premises alarmed? YES NO If Yes please indicate all that apply: Bell alarm Monitored by a Central Station Linked to Insured s Mobile Phone Other Please specify below Fire Protection Details Please indicate all that apply: Smoke Detectors Fire Extinguishers Fire Hoses Fire Alarm Bell only Fire Alarm Monitored Sprinklers Dry Riser Other (specify below)

6 SECTION 2: BUSINESS INTERRUPTION COVER REQUIRED: YES NO Increased Cost of Working Sum Insured Required Indemnity Period: 12/18/24/36 months SECTION 3 & 4: LIABILITY INSURANCE COVER REQUIRED: YES NO Section3 - PUBLIC LIABILITY COVER REQUIRED: YES NO Standard Limit of Indemnity 6,500,000 Section 4 EMPLOYERS LIAILITY COVER REQUIRED: YES NO Standard Limit of Indemnity 13,000,000 Please only complete Basis A or Basis B, as appropriate. (Basis A) Based on Number of Number of Haulage Vehicles Number of Haulage Vehicles Clerical Employees Number of Staff Other Manual Employees Number of Staff Or (Basis B) Based on Turnover & Wage Roll Projections Turnover (Only complete below for risks with Haulage Vehicle Numbers greater than 6) Section Wage Roll Projection Number of Staff Full time staff (Drivers) Part time staff (Drivers) Yard Workers Mechanic(s) Clerical Casual

7 Please give details of all claims made by you/a director/partner/financially associated person(s) have made during the last 5 years: Date of Loss Claim Details Settled Yes/No Settlement Amount Reserve Amount (if Not Settled) Please provide details below of measures taken to prevent further losses: Important: (1) All Indemnity for any part of a business which is subject to cover under this proposal form will not include any risk or part thereof for any business based or products/services supplied to North America or Canada, unless specifically agreed by Underwriters. (2) Cover is not deemed in place until confirmed by Patrona Underwriting Ltd.

8 Declaration: It is essential that every Proposer when seeking a quotation to take out any insurance discloses to the insurers all material facts and information (including all material circumstances) which might influence the judgement of an Underwriter in deciding whether to accept the risk and on what terms. The obligation to provide this information continues up until the time that there is a completed contract of insurance and again where material changes occur during the policy year. I/we declare that, after full enquiry, the contents of this Proposal are true and complete to the best of our knowledge and belief that I/we have not misstated, omitted, supressed any material fact or information. I/we agree that this Proposal together with any other information supplied by me/us shall form the basis of any contract of insurance which may be effected. NOTE: 1. Failure to disclose all material information may result in you being quoted the wrong terms, a claim being rejected or reduced, or the policy being deemed invalid and cancelled from inception. 2. You should also keep your own record (including copies) of all information supplied to us in arranging this Insurance. 3. A copy of this Proposal Form/Statement of Fact is available on written request within three months from the date of the proposal. Signature: Date: Name: Position: Note: This Proposal must be signed by a Director, Partner or equivalent of the Proposer. The person signing this Proposal should be authorised by the Proposer to do so and should make all necessary enquiries of his/her fellow Directors, Officers, Partners and Employees to enable the questions to be answered and on whose behalf he/she signs.