ELECTRADE POLICY PROPOSAL FORM

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1 ELECTRADE POLICY PROPOSAL FORM Please answer all questons, completng the form n nk usng block captals. The completon and sgnature of ths Proposal does not bnd the Proposer or Insurers to complete a contract of nsurance. Please note that you must dsclose all materal nformaton lkely to nfluence the acceptance and/or assessment of your Proposal. If you are unsure whether any tem of nformaton s materal you should nclude t. A falure to do so may gve the Insurers the rght to refuse the clams whch you make, and n certan crcumstances to avod the Polcy altogether. Proposer s Full Name Include all subsdary companes to be nsured If the Proposer s not a lmted company specfy any tradng names and the names of all prncpals and partners. Address Tel Fax Post Code e-mal BUSINESS DETAILS 1. When was the busness establshed? 2. Have you ever traded under a dfferent name? YES NO If YES, please advse detals: 3. Are you engaged n busness solely as an electrcal contractor or electrcan? YES NO If NO, what s your full busness descrpton? 4. Are you a member of the Electrcal Contractors Assocaton? YES NO a member of SELECT? YES NO an NICEIC approved electrcal nstallaton contractor? YES NO If YES, please provde your membershp/regstraton number(s): Page 1 of 6

2 5. What s your estmated Gross Annual Turnover for the next twelve months? Electrcal contractng All other contractng All other turnover 6. Indcate as a percentage of your Gross Annual Turnover, the extent of work n the followng areas Domestc Commercal Industral 7. Indcate as a percentage of your Gross Annual Turnover, the extent of work nvolvng Intruder alarm systems Fre alarm, fre extngushng or fre suppresson systems Computer nstallatons v Industral process control systems v Contracts nvolvng solely testng nspecton or certfcaton of exstng systems or portable applances Other than n respect of v above, do you engage n contracts to provde techncal servces or desgns for a fee where you wll not be undertakng nstallaton work as part of the same contract? YES NO If YES, please provde detals of the servces provded and the fees charged: 8. Please estmate for the next twelve months the maxmum number of persons engaged n the busness and the annual gross salares and wages Maxmum Number Salares/Wages Propretors, partners and drectors not workng manually Non-Manual Employees Propretors, partners and drectors workng manually v Drect Employees workng manually v Labour only subcontractors ncludng agency labour 9. Estmated payments to Bona fde subcontractors (ndependent supply & Fx contractors) for the next twelve months 10. Do you engage n: Contracts performed outsde Great Brtan, Northern Ireland, the Isle of Man or the Channel Islands? YES NO The export of goods or servces to the Unted State of Amerca or Canada? YES NO The constructon of, or any work n, arports, arcraft, watercraft, colleres, mnes, gas, petrochemcal and chemcal works, ralways, ralway nstallatons, power statons, ol refneres, fuel depots, quarres or offshore structures, or nstallatons or at any other stes whch may nvolve specal hazards? YES NO v Work on external aerals or masts or work at heghts exceedng 15 metres or at depths exceedng 3 metres? YES NO Page 2 of 6

3 v v The handlng, storage or use of radoactve or other onsng substances, asbestos or slca or materal contanng slca, explosves, acds, chemcals or gases, or any other dangerous substance? YES NO Or do your subcontractors engage n the use of blow lamps, blow torches, electrc oxy-acetylene or other burnng, weldng or cuttng equpment, or any process nvolvng the applcaton of heat other than electrcally powered solderng rons, away from your own premses? YES NO If YES to any part of Queston 10, please provde full detals 11. Do you own or operate lfts, cranes, hosts, bolers, steam contaners or other pressure vessels? YES NO If YES, are these nspected to comply wth statutory requrements? YES NO 12. Are your busness premses n a good state of repar and your plant and machnery properly fenced and guarded? YES NO 13. Do you check that subcontractors you engage are properly and adequately nsured pror to the commencement of the work they are to perform? YES NO If NO to Queston 11, 12 or 13, please provde full detals 14. Do, or could, any of your processes result n the escape or dscharge nto the atmosphere or land of any toxc or dangerous substance? YES NO 15. Do you: Apply contract condtons that may extend your legal lablty? YES NO Accept or have you accepted onerous contract condtons requrng you to assume the lablty of another party n respect of the neglgent acts, errors or omssons of such other party? YES NO If YES to any part of Queston 14 or 15, please provde full detals COVER REQUIRED 1. Please advse the date the Insurance s to commence: Note: Cover wll not commence untl ECIC have accepted ths Proposal or agreed to hold covered. 2. Please advse the Publc/Product Lablty ndemnty lmt you requre: Note: Lmts of 1,000,000, 2,000,000 or 5,000,000 are avalable 3. Do you requre Employers Lablty cover? Note: The Employers Lablty ndemnty lmt s 10,000,000 any one event ncludng costs and expenses. YES NO Page 3 of 6

4 4. Do you requre Contractor s all Rsks or Tools nsurance YES NO If YES, please select level of cover requred: Contractors all Rsks Tools Insurance Only - Sngle Artcle Lmt 1, In respect of Contracts you may undertake, what s the maxmum: Contract Value (ncludng the value of any Free-ssue Materals and temporary works that you may be responsble for) Contract Perod ncludng any mantenance or defects lablty perod 6. What s the Total current value of the plant, tools and equpment that belong to you Maxmum current value of any one tem n above v Total current value of ste huts and other temporary ste accommodaton (ncludng ther contents) that belong to you Maxmum total value of plant, tools, equpment, ste huts and temporary ste accommodaton hred n by you at any one tme 7. In the course of your busness do you ever hre out plant to other partes? YES NO 8. Do you requre Personal Accdent nsurance YES NO If YES, please select level of cover requred: Prncpals/Partners/Drectors YES NO Number of unts requred per person All other Employees Note: Cover s not avalable for labour only subcontractors 9. Are all persons to be nsured n sound physcal and mental health and free of physcal defect and nfrmty YES NO CLAIMS AND INSURANCE HISTORY YES 1. Have you or any partner or drector (n connecton wth ths or any other busness n whch you or they have been tradng):- Suffered any loss, made any clams or been nvolved n ncdents whch have or could have resulted n a clam n respect of the rsks proposed wthn the last 5- years? YES NO NO Had clams settled or notfed aganst you wthn the last 10 years n respect of an occupatonal llness or dsease (.e. deafness, vbraton whte fnger, repettve stran njury, dermatts, lung dsease or cancer) or polluton or contamnaton? If YES to ether or above, please advse: YES NO Type of Insurance Date of Loss Detals of Loss Amount Pad Amount Outstandng Page 4 of 6

5 2. Please provde the followng nformaton about your present nsurance. If you are not presently nsured (other than where your polcy has recently lapsed) please state none. Present Insurer Renewal Date Employers/Publc Lablty Contractors all Rsks/Tools Personal Accdent 3. Has an nsurer ever declned to nsure you? YES NO cancelled or declned to renew any of your nsurances? YES NO requred specal terms? YES NO 4. Have you or any drector or partner ever been convcted of or charged (but not yet tred) wth any crmnal offence other than motor? YES NO declared Bankrupt or nsolvent? YES NO a drector or partner of a company that went nto lqudaton? YES NO v the subject of a recovery acton by Customs and Excse or the Inland Revenue? YES NO If YES to any part of Questons 3 or 4 above, please advse detals: DECLARATION 1. I/We declare that to the best of my/our knowledge and belef. the statements and partculars suppled by me/us or on my/our behalf n ths proposal are true and complete. any statements or partculars suppled by me/us or on my/our behalf separately are true and complete. that no materal nformaton has been wthheld. 2. I/We agree that ths proposal and any statement and partculars suppled separately shall form the bass of the contract between me/us and the EC Insurance Company Lmted. 3. I/We agree to accept the EC Insurance Company Lmted s usual form of polcy for ths type of nsurance. A specmen copy of the polcy s avalable on request. 4. I/We understand that Insurers share nformaton wth each other, credt reference agences and other nformaton agences wth regard to credt agreements, polces and clams, prmarly to help assess rsks, handle clams and prevent frauds. I/We consent to ths. Authorsed Sgnature Date Materal Informaton Materal nformaton s consdered as facts, whch f dvulged to an nsurer mght be construed as nfluental to hs/ther acceptance of any rsk. If you are unsure whether any fact could be construed as "Materal Informaton" you should dsclose t. We recommend that you should keep a record of all nformaton, ncludng copes of ths proposal form and any letters, suppled to us for the purposes of enterng nto ths nsurance contract. Please let us know f you would lke a copy of ths proposal form sent to you. Page 5 of 6

6 Data Protecton Act We may use the personal and busness detals you gve us, or whch are suppled by thrd partes, to provde you wth a quotaton, to admnster your polcy, to search the fles of credt reference agences who may keep a record of the search, to carry out such fnancal and other enqures as we consder necessary to evaluate the rsk and assst n makng a decson regardng our acceptance of the rsk, to support the development of our busness ncludng your detals n customer surveys, and for market research and complance busness revews. We may also share these detals wth other nsurance organsatons to help off-set rsks, to help admnster your polcy and to handle clams and prevent fraud. We wll store your detals on computer but wll not keep them for longer than necessary. Under the terms of the Data Protecton Act 1998, you are enttled to a copy of all the nformaton we hold about you. Notce to Proposers Under the Insurance Companes (Thrd Insurance Drectves) Regulatons 1994 If you are applyng for nsurance protecton as a prvate ndvdual or as a sole trader (or for the beneft of a prvate ndvdual or sole trader) you should carefully read the followng nformaton. Law Applcable to the Contract The law applcable to ths nsurance contract s subject to agreement between the partes. Unless a specal endorsement to the contrary has been requested by you and agreed by us the law applyng to ths Insurance contract wll be as follows: a. f you are applyng for nsurance protecton as a prvate ndvdual the law applcable to that part of the Unted Kngdom, Channel Islands or Isle of Man n whch you or the frst named polcyholder normally resdes, or b. f you are applyng for nsurance protecton n your capacty as a sole trader the law applcable to that part of the Unted Kngdom, Channel Islands or Isle of Man n whch you have your prncpal place of busness, or c. f nether of the above apples, the Law of England and Wales. EC Insurance Company Lmted (Company No ) Regstered n England and Wales at ECA Court, South Park, Sevenoaks, Kent TN13 1DU. Customer Care EC Insurance Company Lmted ('ECIC') s commtted to mantanng a hgh standard of professonal conduct n all our dealngs wth customers. However f you feel that your nsurance arrangements have not been handled n the manner n whch you would expect and you wsh to make a complant, please contact the Underwrtng Manager at the offce of ECIC that ssued your polcy. We wll ensure that the matter receves mmedate attenton. You wll be sent a copy of our Complants Handlng Procedure. If you feel that the matter has not been settled to your satsfacton you may wrte to the General Manager, ECIC, ECA Court, South Park, Sevenoaks, Kent TN13 1DU. If you are not satsfed wth our nvestgaton and concluson of your complant or eght weeks have passed snce ntally makng your complant and you are an ndvdual consumer or a busness wth a group annual turnover of less than 1mllon you may refer the matter to the Fnancal Ombudsman Servce, South Quay Plaza, 183 Marsh Wall, London E14 9SR. ECIC s a member of the Assocaton of Brtsh Insurers and a member of the General Insurance Standards Councl. ECIC s authorsed by the Prudental Regulaton Authorty and regulated by the Fnancal Conduct Authorty and the Prudental Regulaton Authorty. Your rght as a polcyholder to take legal acton remans unaffected by the exstence of the complants procedures referred to above. Page 6 of 6

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