Management Liability Policy Standard proposal form (with premiums) Who can use this proposal form This proposal form is only for: UK registered Private Limited companies with an annual turnover of up to 50m. UK registered Charities, clubs or associations with an annual income of up to 2m. If your organisation is larger than this, or is a listed company, please use our extended proposal form. This product is NOT suitable for: law firms, or other companies in the legal sector professional football or rugby clubs financial services companies that are directly regulated by the Financial Services Authority sole traders, partnerships or limited liability partnerships. Checking the form Before completing this form, please check that you have the latest version. You can do this by speaking to your nearest AXA Trading Centre or by logging on to the AXA website through imarket (www.imarket.co.uk). Please check all the details you have provided are full and true. Please make sure that you include all relevant information: this is information that could affect our decision to give you insurance or affect the terms we give you. If you are not sure if something is important or relevant you should tell us. These details will form the basis of the insurance contract between us. If you fail to give full and true answers, your policy may not protect you in the event of a claim. Please read the Data Protection notice at the end of this proposal form carefully. Please keep a record of all information given to us (including copies of letters or emails), and a copy of this proposal form as it is part of your insurance policy. Copies of documents If you need a copy of this proposal form, please contact us. We can supply copies up to three months after receiving the form. Please also contact your insurance adviser if you would like a copy of the policy wording. Law applicable to the policy You and we can choose the law which applies to this policy. We propose that English law applies. Unless we and you agree otherwise, English law will apply to this policy. AXA Insurance UK plc is authorised and regulated by the Financial Services Authority. This can be checked on the FSA s website at www.fsa.gov.uk/register or by contacting them on 0845 606 1234. AXA Insurance UK plc. Registered in England. 78950. Registered Office: 5 Old Broad Street, London EC2N 1AD. A member of the AXA Group of Companies. AXA Insurance UK plc is authorised and regulated by the Financial Services Authority. Telephone calls may be monitored or recorded. 1 of 8
1 Your details Your business 1.1 Type of company or organisation Charity Club Association Private Limited company please tick your business sector Construction Education/social Leisure Manufacturing Motor trade Professional services Property owners or managers Retail or wholesale Transport Other please give details 1.2 Registered name 1.3 Registered address Postcode Your cover 1.4 Turnover or income in the last 12 calendar months 1.5 When would you like the cover to start? Your cover will only start when AXA accepts your proposal. D D M M Y Y 1.6 Please tick if you only need a quote Quote only 2 of 8 34514_ACLD0375XD_APP.indd 2 21/02/2013 14:22
2 General questions If you tick a highlighted box for any of the questions in section 2, please provide full details at the end of the section. 2.1 Have you been trading for at least 12 months? 2.2 Have you made any redundancies in the last 6 months, or do you plan to make any redundancies in the next 12 months? 2.3 Is your organisation regulated by the Financial Services Authority? 2.4 Do you use external Human Resources consultants or legal advisors to review all employment terminations? 2.5 Do you communicate written employment and grievance policies to all new and existing employees? 2.6 Other than directors, are all duties segregated so that dual controls exist on signing cheques above 2,500 and issuing instructions for disbursement of assets or funds? 2.7 Do you have any assets in the United States of America (USA), or does your turnover or income include any turnover or income from the USA? 2.8 In the last 5 years, have there been any claims or investigations made against you, or against any directors, trustees, officers or employees, that this policy might have covered if it had been in force? 2.9 After full enquiry, are you or any of your directors, trustees, officers, or employees aware of any fact or circumstance that may lead to a claim under the proposed policy? Before answering this question, you must ask all directors, trustees, officers and employees for full information. 2.10 Have you previously held Directors & officers or Trustees liability cover? when did your previous cover first start? D D M M Y Y If your organisation is a Private Limited company, please answer question 2.11, then go to Section 3. 2.11 Did you make a profit (that is, a net profit after tax) in the last 12 months? 3 of 8 34514_ACLD0375XD_APP.indd 3 21/02/2013 14:22
2 General questions continued If your organisation is a charity, club or association, please answer questions 2.12 to 2.14, then go to Section 3. 2.12 Have you made a surplus (that is, your income was greater than your expenditure) in at least one of the last three years? 2.13 Do you have a positive net worth? (That is, your total assets are worth more than your liabilities) 2.14 Do you provide any of the following services? Management or supervision of children or vulnerable adults Certification, examination or regulation of your members Financial or legal advice for a fee If you have ticked any of the highlighted boxes, please provide full details here. If you need more room, please attach additional sheets, adding your company name to each. If you have attached any additional sheets, please write your company name on each sheet, and fill in the number of additional sheets here. additional sheets 4 of 8 34514_ACLD0375XD_APP.indd 4 21/02/2013 14:22
3 Limits of cover, premiums and excesses Please note: if you have ticked a highlighted box and given extra information for any of the questions in Section 2, we will need to consider the information you have given us before we can confirm your premiums and excess levels. This means that your premiums and excesses may be different from those shown below. Our terms of cover may also be different. Please fill in this section to show the cover you need, and we will confirm your premium as soon as we have reviewed the extra information you provided. Limits of cover for private limited companies The limit of cover will apply separately to each section of cover. The policy sections are: Directors and officers liability; Employment practices liability; and Company legal liability. 3.1 Please tick the limit of cover you require for your company Limit per section any one claim including costs Annual turnover Up to 1,000,001 2,500,001 10,000,001 25,000,001 1million to 2.5million to 10million to 25million to 50million About these premiums Please note: these premiums only apply if you have not ticked any of the highlighted boxes in Section 2. These premiums change from time to time. Please check that you are using the latest version of this form. 250,000 450 640 925 1,160 1,335 500,000 735 870 1,160 1,400 1,575 1,000,000 930 1,160 1,500 1,700 1,850 2,000,000 1,150 1,500 1,975 2,200 2,400 5,000,000 2,320 2,900 3,950 4,640 5,510 The premiums shown above include an amount of 10% including VAT for access to the specialist Rradar advisory service. The remainder of the premium includes IPT at the current rate. Limits of cover for charities, clubs and associations The limit of cover will apply separately to each section of cover. The policy sections are: Trustees liability; Employment practices liability; and Charities, clubs and associations legal liability. 3.2 Please tick the limit of cover you require for your charity, club or association Limit per section any one claim including costs Annual income Up to 100,001 250,001 500,001 1,000,001 100,000 to 250,000 to 500,000 to 1million to 2million About these premiums Please note: these premiums only apply if you have not ticked any of the highlighted boxes in Section 2. These premiums change from time to time. Please check that you are using the latest version of this form. 100,000 290 400 580 930 1,160 250,000 465 585 810 1,050 1,335 500,000 580 810 1,160 1,400 1,565 1,000,000 755 1,050 1,400 1,565 1,740 2,000,000 1,160 1,400 1,565 1,740 1,975 5,000,000 2,320 2,900 3,770 4,060 4,640 The premiums shown above include an amount of 10% including VAT for access to the specialist Rradar advisory service. The remainder of the premium includes IPT at the current rate. 5 of 8 34514_ACLD0375XD_APP.indd 5 21/02/2013 14:22
3 Limits of cover, premiums and excesses continued Your excesses section Directors & officers or Trustees liability section Employment practices liability section Company or Charities, clubs and associations legal liability section your excess Nil 3,750 each and every claim including defence costs. The excess will not apply where the advice of the employment helpline is followed for any employment matter that may lead to a claim. 2,500 each and every claim including defence costs. The excess will not apply where you have followed the advice of the legal and regulatory helpline for any matter that may lead to a claim. Legal and employment helplines Your cover includes access to helplines that you can contact for free advice on employment, regulatory and other legal matters relating to your policy cover. 6 of 8 34514_ACLD0375XD_APP.indd 6 21/02/2013 14:22
4 Declaration If you have not given full and true answers to all questions asked on this proposal form, your insurance may not protect you in the event of a claim. Before signing the declaration, please read the following Data Protection notice AXA Insurance UK plc is a member of the AXA Group. In order to supply your quote and then to administer your insurance policy, we will hold and use information including sensitive personal data and claims information you provide and may send it in confidence for secure processing to other companies in the AXA Group (or companies acting on our instructions) including those located outside the European economic area. Please read this declaration carefully and then sign below I/We agree that the policy, the policy schedule and this proposal form and any additional information given will be the basis of the contract between me/us and AXA Insurance UK plc. I/We understand that all relevant information, which is information that may influence AXA Insurance UK plc in the acceptance of this insurance and the terms provided, has been disclosed and recorded. I/We declare that all particulars given in this proposal form whether made by me/us or on my/our behalf are true and complete. I/We understand that if full and true answers have not been given or if all relevant information has not been disclosed that this insurance may not protect me/us in the event of a claim. I/We will tell you of any change to the details given before the start date of the contract. Signature of Chairman, Managing Director, Trustee or equivalent Name Position in company Date D D M M Y Y AXA Insurance UK plc may occasionally contact you with details of our other products and services. If you do not wish to receive this information from AXA Insurance UK plc, tick this box. We may provide information supplied by you to selected third parties, who may contact you in relation to the provision of insurance-related services. If you do not wish us to provide your details to third parties, tick this box. Agent name and address 7 of 8 34514_ACLD0375XD_APP.indd 7 21/02/2013 14:22
www.axa.co.uk ACLD0375X-D (02/13) (34514) 34514_ACLD0375XD_APP.indd 8 21/02/2013 14:22