Brooks Braithwaite (Sussex) Ltd Animal Centres / Sanctuaries Proposal Form. 15th May 2015
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1 Brooks Braithwaite (Sussex) Ltd Animal Centres / Sanctuaries Proposal Form 15th May 2015
2 Important Informa on To apply for Public and/or Employers Liability Insurance, complete this proposal form in BLOCK CAPITALS using blue or black ink. Please use a separate sheet of paper if required. You must provide full and true answers to all ques ons. If you do not do so, your insurance cover may not protect you in the event of a claim. If you are in any doubt regarding any of the answers, please contact Brooks Braithwaite (Sussex) Ltd. Proposer s Details Customer reference number Full name of proposer 1 Full name of proposer 2 Proposer 1 s posi on within the organisa on Proposer 2 s posi on within the organisa on Are all the proposers over 18 years of age at the me of applying for insurance? Organisa on s name Companies house registered number Registered charity number Addi onal named persons, a named person is someone with whom we may discuss your policy/proposal details Addi onal named person 1 Addi onal named person 2 Correspondence address Contact telephone number 1 Contact telephone number 2 address A risk address is a regular premises where the animal(s) are kept/event(s) take place. If you do not have a regular premises please state not applicable Risk address
3 How did you hear about our insurance? Date cover is required from? Previous History The following ques ons are to be answered in respect of you, all proposers and all Directors or partners in the organisa on proposed or in the name of any other organisa on in which any of you, all proposers and all Directors or partners have had an interest. Have you, or any proposers, Directors or partners in the organisa on been insured for these risks before? If, please provide details of the names of the insurance company, policy numbers and cover from and to dates Have you, or any proposers, Directors or partners in the organisa on ever had any insurance of a similar nature declined, cancelled, refused or had special terms or condi ons imposed? If, please provide further details Have you, or any proposers, Directors or partners in the organisa on proposed incurred any liability in the last 5 years which has, or could have resulted in a claim? If, please provide details of the date of incident, amount paid, amount outstanding and details surrounding the incident. In the last 5 years, have you, or any official, owner, director, manager, other person connected with this proposal ever been convicted of, or are due to stand trial for; any offence involving arson, criminal decep on, fraud, forgery, the, robbery, handling stolen goods, any crime of violence or any other offence other than a motoring convic on? If, please provide further details In the last 3 years, have you, or any official, owner, director, manager, other person connected with this proposal ever been declared bankrupt, received a county court judgement, have any outstanding arrangements with creditors or been a director or partner of a company that went into liquida on? If, please provide further details Have you, or any official, owner, director, manager, other person connected with this proposal ever been prosecuted under any Health and Safety at Work Act(s) or been in breach of any laws related to Health and Safety? If, please provide further details
4 In the last 5 years have you made any previous property claims? If, please provide further details General Ques ons Details of ac vi es e.g. Dangerous Wild Animal(s) kept on a private home premises, Shows displays and events with animals, Pet Par es, Animal educa onal talks, Pe ng zoos, Sta c and flying displays of birds of prey, Bird of prey experience days, Vermin clearance with birds of prey, Privately flying pet birds of prey, Animals kept in outside paddocks, How long has the organisa on been established? What was the annual turnover of the organisa on in the last 12 months or if a new venture the projected turnover? Is the organisa on licenced under the zoo licensing act 1981? Licence Number If, please provide further details of why no licence is in place Cover Required Do you require cover for: Public Liability? Public Liability insurance covers clients for legal liability to third par es, including related legal costs if a third party is injured or their property is damaged. Employers Liability? Employers Liability insurance covers clients for their legal liability to pay compensa on and claimants costs and expenses in respect of an injury sustained by an employee arising out of or in the course of the employee s employment. It is a legal requirement to carry employers liability for all employees including handlers/volunteers whether full or part me Product Liability? Product Liability insurance covers clients for their legal liability to third par es for the cost of compensa ng anyone who is injured by a faulty product that your organisa on designs, manufactures or supplies. Commercial Buildings? Commercial Buildings insurance covers clients for damage to the commercial buildings at the premises caused by any of the Events (including Fire, Explosion, Earthquake, Storm, and Flood) opera ve under this Policy and not otherwise excluded occurring during the period of insurance
5 Contents? Contents insurance covers clients for damage to the commercial contents at the premises caused by any of the Events (including The, Fire, Explosion, Earthquake, Storm, and Flood) opera ve under this Policy and not otherwise excluded occurring during the period of insurance Stock? Stock insurance covers clients for damage to the commercial stock at the premises caused by any of the Events (including The, Fire, Explosion, Earthquake, Storm, and Flood) opera ve under this Policy and not otherwise excluded occurring during the period of insurance Internal Fixed Glass? Internal Fixed Glass insurance covers clients for damage to the internal fixed glass at the premises caused by any of the Events (including Fire, Explosion, Earthquake, Storm, and Flood) opera ve under this Policy and not otherwise excluded occurring during the period of insurance Computer & Other Business Equipment? Computer & Other Business Equipment insurance covers clients for damage to the computers and other business equipment at the premises caused by any of the Events (including Accidental Damage, The, Fire, Explosion, Earthquake, Storm, and Flood) opera ve under this Policy and not otherwise excluded occurring during the Business Machinery? Business Machinery insurance covers clients for damage to the business machinery at the premises caused by any of the Events (including Accidental Damage, The, Fire, Explosion, Earthquake, Storm, and Flood) opera ve under this Policy and not otherwise excluded occurring during the period of insurance Business Interrup on? Business Interrup on insurance covers loss resul ng from interrup on of or interference with the Business carried on by the Insured at the Premise in consequence of an event to Property. Benefit payable up to 12 months following the event and is based on annual revenue Money? Money insurance covers damage to Money occurring during the Period of Insurance held in connec on with the Business by any cause not excluded, The or a empted The of Money held in connec on with the business and injury or emo onal stress to an insured person whilst engaged in connec on with the business as a direct result of the or a empted the of Money involving assault or violent or the threat there of. Public Liability What level of Public Liability cover is required? 1 million 2 million 5 million
6 Please list all species of animals to be covered and the number of each species Species Number of each species Are any of the animals required to be licenced under the Dangerous Wild Animals Act 1976? If, please advise the type of licence held i.e. dangerous wild animals licence, pet shop licence, zoo licence and the licence number Are all the animals owned by a proposer or the organisa on? If, please provide details of who owns the animals Will you, a proposer, employee, volunteer, director or partner of the organisa on be supervising the public at all mes while the public have access to view or handle the animals? Will members of the public be able to handle the animals? Have any of the animals shown vicious tendencies previously? Will the animals be taken off the correspondence and/or risk address? If, please answer the following addi onal ques ons Under what circumstances will the animals be taken off the correspondence and/or risk address? How many mes per annum would the animals be taken off the correspondence and/or risk address? Will you, a proposer or the organisa on, be responsible for or provide any of the following ac vi es/facili es (these ac vi es/facili es are not covered as standard)? - Cafeteria - Gi Shop - Swimming pool - Barbeques - Play ground/area - Fireworks or bonfires - Inflatable play equipment - Circus acts or stunts - Pyrotechnical devices - It s a knockout compe ons - Persons riding animals - Bike Hire
7 - Ballooning or flying of any descrip on - Shoo ng ranges for guns or archery - Canoeing, sailing or the use of water cra - Quad bikes, go-karts or motor sports of any kind - Fairground rides or mechanical or electrical rides of any kind - Trampolines, gymnas c apparatus or any apparatus - Other, please specify.. requiring the use of safety harness or ropes to prevent or. arrest falls from height If, please provide details of the ac vi es taking place? Will the organisa on proposed be organising any events? If, please answer the following addi onal ques ons What type of event(s) will be organised? What ac vi es will be provided at the event(s)? How many events will be organised per annum? What will be the total number of visitors per event? Do you have a fully documented risk assessment and health and safety policy for the event(s)? Will sea ng, staging or marquees be erected at the event? If, will this be erected by the proposed organisa on or a third party? Will any contractor, performer or exhibitor have their own third party insurance? If, please provide further details of when this will occur Will any of the following ac vi es be taking place at the event for which the proposer(s)/organisa on are responsible for (these ac vi es are not covered as standard)? - Fireworks or bonfires - Circus acts or stunts - Inflatable play equipment - Pyrotechnical devices - It s a knockout compe ons - Persons riding animals - Barbeques - Bouncy castle or other inflatables - Shoo ng ranges for guns or archery - Ballooning or flying of any descrip on - Quadbikes, go-karts or motor sports of any kind - Canoeing, sailing or the use of watercra - Fairground rides or mechanical or electrical rides - Trampolines, gymnas c apparatus or any apparatus of any kind requiring the use of safety harness or ropes to prevent or arrest falls from height If, please provide details of the ac vi es taking place?
8 Will there be any naked flames or burning embers (including but not limited to, candles, t-lights, braziers, burners or incense) being used at the event? Will there be first aid provided at the event? If, will this be provided by the proposed organisa on or a third party? Employers Liability Does the organisa on have over 10 employees/volunteers (including both full and part me workers)? If, please provide details of the number of full me employees/volunteers and part me employees/ volunteers What was the wage bill of the organisa on in the last 12 months or if a new venture the projected wage bill? Do you or the organisa on have an Employers PAYE reference? If, please provide your reference i.e. 123/A1234 If, please provide details to explain why not e.g. below threshold or only have unpaid volunteer(s) If the organisa on is a limited company, does the organisa on have any subsidiary companies? If, please state name, address, companies house registered number, employers PAYE reference for the subsidiary company and whether the limited company proposed is a majority shareholder in the subsidiary company Product Liability Are all the products sold by you or the organisa on manufactured by third par es? If, Please provide details of any products manufactured by the proposer(s) or the organisa on Are any of the products sold outside of the UK? Do you maintain a system of records which would enable iden fica on of the source of products purchased? Would it be possible to recall all products if required?
9 Commercial Buildings Are the commercial buildings of standard construc on (i.e. built of brick, stone or concrete walls and roofed with slates, les, asphalt, metal or concrete)? If, Please provide details of the construc on of the buildings Are the commercial buildings of non standard construc on (i.e. not built of brick, stone or concrete walls and roofed with slates, les, asphalt, metal or concrete)? If, Please provide details of the construc on of the buildings Does any part of the buildings have a thatched roof? If, Please provide details of the percentage of the roof which is thatched and when the thatched roof was last replaced and or inspected. Is there any flat roofing on the buildings? If, Please provide details of the percentage of the roof which is flat What is the sum to be insured for buildings of standard construc on? What is the sum to be insured for buildings of non standard construc on? Do you require accidental damage on buildings? Are any of the commercial buildings of listed status? If, Please provide listed status of the building In what year was the property built? Are the premises heated by portable paraffin or LPG heaters? If, Are the cylinders kept in a designated cage? Is the property in a good state of repair? If, Please provide further details
10 Do any par es have a financial interest in the commercial property? E.g. bank/building society If, Please state the name of bank/building society or third party Contents Contents designed to include fixtures/fi ngs, office furniture, floor coverings, portable heaters, fire figh ng equipment etc What is the sum to be insured for contents? Do you require accidental damage on contents? Are the premises heated by portable paraffin or LPG heaters? If, Are the cylinders kept in a designated cage? Stock Stock designed to include your stock, including item for resale but excluding animals at your premises What is the sum to be insured for Stock? Do you require accidental damage on Stock? Are the premises heated by portable paraffin or LPG heaters? If, Are the cylinders kept in a designated cage? Internal Fixed Glass Internal Fixed Glass designed to include glass par oning, display cabinets etc What is the sum to be insured for Internal Fixed Glass? Are the premises heated by portable paraffin or LPG heaters? If, Are the cylinders kept in a designated cage? Computer & Other Business Equipment Computer & Other Business Equipment designed to include computers, word processors, VDU s, keyboards and printers, facsimile machines, photocopiers and telecommunica ons equipment What is the sum to be insured for Computer & Other Business Equipment? If any one item is valued over 1000 please provide details including sum(s) insured and make, model, serial number if applicable?
11 Are the premises heated by portable paraffin or LPG heaters? If, Are the cylinders kept in a designated cage? Business Machinery Business Machinery designed to include machinery, lawnmowers, power washers, generators etc What is the sum to be insured for Business Machinery? If any one item is valued over 1000 please provide details including sum(s) insured and make, model, serial number if applicable? Are the premises where the business machinery is kept heated by portable paraffin or LPG heaters? If, Are the cylinders kept in a designated cage? Business Interrup on Business Interrup on is only available provided buildings and/or contents cover are purchased. What is your annual revenue? Money Which fixed limit of cover do you require for cover fro money on the premises and in transit? 4,000 8,000 Payment Op ons Please confirm your method of payment? Credit Card Debit Card Cheque Direct Debit 2% surcharge applies 10 payments interest free 0% APR Data Protec on Act Clause By signing this Proposal Form I/We hereby consent to any informa on you may have about me/us being processed by you for the purpose of providing insurance and claim handling which may necessitate your providing Informa on we need to know about Important ce The informa on you have provided in this form contains statements upon which Underwriters will rely when deciding whether to accept this insurance and the terms on which it may be offered, including the amount of premium payable. Should a contract be concluded this proposal will form the basis of the insurance. If you are in any doubt at all regarding any of the answers you have given, you should contact Brooks Braithwaite (Sussex) Ltd. You must tell us as soon as you become aware of any changes to the informa on provided by you a er you purchase your policy and during the period of your policy.
12 Declara on To the best of my knowledge and belief the informa on provided in connec on with this proposal, whether in my own hand or not, is true. I understand that non-disclosure or misrepresenta on of any of the answers given may en tle Underwriters to: Cancel my policy and refuse to pay any claim, or not pay any claim in full, or revise the premium and/or change any excess, or revise the extent of cover or terms of this insurance Signature of proposer 1 Print name Date Signature of proposer 2 Print name Date
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