PROPOSAL FORM GENERAL BUSINESS LIABILITY INSURANCE

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1 PROPOSAL FORM GENERAL BUSINESS LIABILITY INSURANCE This proposal form must be completed, signed and dated by a Partner, Principal or Director of the firm who has been duly authorised by all Partners, Principals or Directors for this purpose. Please read the following information carefully as this forms an important part of any Insurance bound. MATERIAL FACTS A Material Fact a fact which may influence a (re)insurer s judgement in their assessment of a risk, including its terms and pricing. Therefore it is your duty to disclose all material facts as this may affect the validity of these terms and any Insurance bound subsequently. If you are in any doubt as to whether a fact is material we recommend that it be disclosed. You should also keep us advised of any changes to Material Facts as these may also need to be disclosed. Failure to disclose Material Facts may entitle (re)insurers to avoid the policy from inception. Examples of Material Facts are: 1. Circumstances which might give rise to a Claim or 2. Information on the nature of the work undertaken or 3. Change to the location of work (i.e. territories overseas not previously advised) You should keep a record of all information supplied to the Insurer. Answers such as See Presentation or See your records should not be used. You must answer all questions correctly and provide all material information. Failure to do so may prejudice you under the Policy or the premium that are requested to pay. If there is insufficient space to answer questions, please use an additional sheet and attach to this form. 1 Name(s) of Company / Sole Trader to be insured including any Subsidiary Company(s) to be included in this Insurance:... Address (including Postcode):.. Telephone Number:.... Fax Number: Website:.. address: 2 Business Description:..... Describe Processes and Activities: Page 1 of 10

2 3 Should you require Employers Liability, the following information MUST be provided: Employer Reference Number (ERN) also Full Name & Address of any subsidiary referred to as Employee PAYE Reference for Companies: both the Insured and their Subsidiaries: Date Established:.. If new, give details of experience:.. Confirm local Authority and H.S.E Registration: Have you entered into any contract which imposes upon you liability for which you would not otherwise be liable? 5 Do you own premises or have any representation outside the United Kingdom? If YES please provide full details:.. Is this operation(s) the subject of local Insurance arrangements? If YES please provide full details:.. 6 Are all employees United Kingdom nationals? If NO state number and Nationality of foreign employees:.. 7 Do you use Sub-Contractors? If YES do you check they hold their own Insurance and are therefore not to be covered under your Policy? 8 Have you or any of your Directors or Partners ever been charged with a Criminal offence other than a motoring offence? Has any Insurer ever declined to insure you or refused to renew any of your insurances? YES /NO If you answered YES to any of the above, please provide full details (including identity of Insurers): 9 Please provide details of present Liability Insurer(s), expiry date(s) and policy number(s): Page 2 of 10

3 10 Give details of any separate business in which you or your Directors or Partners are or have been involved during the last 5 years. Name of Business Trade From To 11 If cover is required outside the UK mainland, please state in which Countries and locations (i.e. Republic of Ireland/Northern Ireland, West Africa and/or North America) and Summarise activities undertaken: 12 Do you require: Employers Liability Public/Products Liability Yes No Indemnity Limit Required GBP GBP Date from which cover is to commence: 13 EMPLOYERS LIABILITY RISK PROFILE EMPLOYERS AND PUBLIC/PRODUCTS LIABILITY Summarise estimated annual payments to all Employees and including Labour Only Sub Contractors.(Payments means wages, including overtime, standby time, bonuses, National Insurance and Pension contributions and Income Tax). Category Estimated number of Employees Location Estimated Annual payments to all Employees Actual Annual Payments for last 12 months Clerical/Managerial Manual - Premises Manual Work Away excluding Heat Manual Work Away including Heat Offshore Payments to Bona- Fide Subcontractors All Other Employees (please specify functions) Page 3 of 10

4 14 PUBLIC/PRODUCTS LIABILITY Turnover Actual/Previous 12 Months Estimated Next 12 Months United Kingdom USA/Canada (please specify) Any other Turnover 15 PREMISES Please provide full details Address Purpose Owned/ Sole / Leased Multi Occupation a) b) c) 16 ACTIVITIES - Do your activities include any of the following? a) berthing facilities for ships/watercraft b) landing facilities for aircraft/hovercraft c) railway sidings, terminals or crossings d) fork-lift trucks, bobcats, JCB s or other rider operated plant e) toxic or harmful substances likely to produce significant pollution if not contained on site or correctly discharged Please enter full details here (including numbers and type of fork-lift trucks and other rider operated plant): 17 WORK AWAY If you undertake work away from your premises other than collection and delivery, sales, promotional trips and exhibitions: a) What is the nature of such work? b) Is work in excess of 15 metres high? c) Is it on or within aircraft, airports, ships, docks, mines, chemical, gas or oil processing plants or storage/container installations or nuclear installations? d) Is it on or within offshore installations? Page 4 of 10

5 e) If you use heat away what type of cutting/grinding/burning equipment is used? f) Do you have a safe working with heat equipment procedure? Please provide full details here: PLEASE PROVIDE FULL DETAILS IN RELATION TO THE FOLLOWING HEALTH AND SAFETY QUESTIONS Your answers to the questions under Section 18: Health and Safety at Work and Welfare will be taken into consideration as part of the investigation process in the event that you make a Claim under the policy. When dealing with Claims, we will consider whether poor Health and Safety controls may have contributed to the incident and this may be reflected in the renewal premium. 18 HEALTH AND SAFETY AT WORK AND WELFARE GENERAL a) Do you have a Health and Safety policy which is available to your staff and visitors? (if yes, please append a copy to this submission) b) By what processes to you ensure that your Health and Safety policy is kept up to date? c) By what process do you minimise the likelihood of recurrence following an accident at work? d) How do you benchmark your Health and Safety processes and performance either internally or externally? e) Please confirm that you always retain the following documentation: Health and Safety risk assessment records Instruction and training records Method Statements / work instructions RIDDOR Forms Contract and Sub-Contract documentation Copies of certificates of Insurance issued to CIS5 and CIS6 holders f) Please advise any dealings that your Company has had in the last 5 years with the Health and Safety Executive, an Environmental Health Officer or any other enforcement agency and if you have been the subject of enforcement measures, prohibition notices or criminal proceedings: Page 5 of 10

6 RISK ASSESSMENT g) How do you assess and minimise the risk to Health and Safety arising from the following; a) (i) The provision and use of work equipment: (ii) Fork-lift Trucks or other rider operated plant (1) Are all of your Fork-lift Truck or other rider operated plant drivers at least 18 years of age and trained in accordance with the HSE Code of Practice 26 or any replacement regulations? (2) Have all Fork-lift Truck operatives completed a training course In the safe use of Fork-lift Trucks through an Accredited Training Provider belonging to one of the 5 accredited bodies as recognised By the HSE? (3) Do the operatives complete a refresher course within 5 years of the initial training programme? b) Manual Handing:.. c) Noise in the workplace (Processes in excess of 85dB (A)): d) Substances hazardous to health: e) Hand/arm vibration.. f) Repetitive strains g) Stress h) Working at heights h) In relation to any construction or building operations, what steps are taken to ensure compliance with Construction (Health, Safety and Welfare) Regulations?.... i) What steps are taken to ensure compliance with Workplace (Health, Safety and Welfare) Regulations? Page 6 of 10

7 j) Have you documented your strategy for compliance as a Duty Holder under the Control of Asbestos at Work Regulations 2002 and prioritised action? MANAGING SAFETY k) Please describe the company training and instruction policy with reference to certification, induction training and toolbox talks: l) Please describe the Company policy on Personal Protective Equipment with special reference to enforcement: m) Please provide any other information, regarding Health and Safety at Work or otherwise, which you believe to be relevant to Insurers consideration of this risk. WELFARE n) In the event that an Employee is injured at work, do you, as a matter of policy; (i) Provide rehabilitation/medical care to facilitate the return to work? (ii) Continue to pay the Employee s wages following the accident? If so, on what basis? (iii) Make efforts to re-deploy Employees on alternative tasks/jobs during recovery period? (iv) Pursue other forms of initiatives to accelerate well being and return to fitness? PRODUCTS PROFILE PRODUCT LIABILITY AND QUALITY MANAGEMENT 19 a) Please provide a detailed description of products supplied, and, if appropriate, terms of hiring out agreements: b) Please provide details of products exported to the USA or Canada within the last 3 years: c) Please provide full details of any product used i) in aircraft: ii) in marine craft: iii) offshore: d) Please provide full details of imported products including source of origin and amount: Page 7 of 10

8 e) If you provide any services or treatment other than products please provide details: f) Do you retain Rights of Recourse against manufacturers/suppliers? g) Do any of your products require an accompanying hazard warning? h) Do you design or prepare specifications for the products you supply? If YES, please provide full details (including qualifications of design team): i) Please provide details of your quality control systems and procedures (e.g. ISO 9000) including any early warning mechanism built into your complaints procedure: j) Please provide details of any product line know to be harmful to health: k) Please indicate period of time, in years, that you retain stock records of: Customers. Suppliers. 20 Please provide full details of work undertaken including involvement with any trade acknowledged hazardous substances: 21 Have you any history of prolonged absence of employees due to stress? If YES, please provide full details: 22 Are you aware of any recorded instances/claims for GDD (Gradually Developing Diseases) such as Deafness, Repetitive Strain Injury, Vibration White Finger, Chest/Lung Condition/ Cancer, Asbestosis (or similar conditions) made against you or about to be made against you? If Yes, please provide the following information: Year Type of GDD No. of Claim Amount of Claim Insurer Page 8 of 10

9 23 CLAIMS EXPERIENCE Please confirm that you have approved the authenticated Claims Experience supplied by your Broker which forms part of this Proposal CLAIMS HISTORY RECORD Details of all Claims made against the Proposer during the past five years. FOR EMPLOYERS LIABILITY State number and details of accidents to your Employees during the past five years in respect of Claims made against you (please use a separate sheet if necessary) YEAR HISTORIAL MANUAL WAGES SETTLED CLAIMS RESERVES FOR OUTSTANDING CLAIMS NUMBER COST NUMBER COST Please provide separate details in the space below of claims and/or any other incident in the last five years not included in (a) above reported under RIDDOR. (please use a separate sheet if necessary) FOR PUBLIC/PRODUCTS LIABILITY State number and details of all Public/Products Liability claims made against you during the past five years. YEAR HISTORIAL TURNOVER SETTLED CLAIMS RESERVES FOR OUTSTANDING CLAIMS NUMBER COST NUMBER COST In respect of Public Liability, please supply details of any other allegations made against you by any Third Party but where no formal Claim has been made by them &/or advised to your Insurers by you (please use a separate sheet if necessary): Page 9 of 10

10 24 Please provide below (or attach a separate sheet to this form) any additional information that you wish to bring to the attention of the Insurer(s):... DECLARATION NOTICE AND WARNING ABOUT MATERIAL FACTS ON PROPOSAL FORM. Please be reminded that failure to disclose all material information, i.e. Information which is likely to influence the acceptance of the risk and the terms applied, could invalidate the Insurance. If you are in any doubt as to whether any information is material, it should be disclosed. I declare that the statements and particulars in this Proposal Form are true and no Material Facts have been suppressed. I / we understand that this Proposal, together with any other information supplied, shall form the basis of any contract of Insurance hereafter. I / we confirm that no work is intentionally undertaken which involves the handling and / or stripping out of asbestos insulation, asbestos coating, asbestos insulation board and/or any other substance incorporating asbestos. I / we undertake to inform Insurer s of any material alteration to these facts occurring before the completion of the contract of Insurance. I /we hereby authorise the Insurers to approach any of my/our previous Insurers to confirm the accuracy of any information given in this Proposal. Signed on behalf of the Proposer Print Name Position Date Page 10 of 10

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