DICKSON MANCHESTER. Charity and Association Liability Proposal Form. Proposal form for Insurance effected through Dickson Manchester & Co Ltd

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1 DICKSON MANCHESTER Charity and Association Liability Proposal Form Proposal form for Insurance effected through Dickson Manchester & Co Ltd A SUBSIDIARY OF HCC INSURANCE HOLDINGS, INC. Member of the General Insurance Standards Council

2 IMPORTANT TICE This proposal must be completed and signed by a Principal, Partner or Director of the Proposer.The person completing and signing the form should be authorised by the Proposer to do so and should make all necessary enquiries of his fellow Partners, Directors and Employees to enable all the questions to be answered. All questions must be answered to enable a quotation to be given. Completing and signing this proposal does not bind the Proposers or Underwriters to enter a contract of insurance. If there is insufficient space to answer questions, please use an additional sheet and attach it to this form (please indicate section number). E.U. DISCLOSURE CLAUSE (UK) ONLY APPLICABLE TO PRIVATE INDIVIDUALS AND SOLE TRADERS,WHERE THERE IS A LLOYD S PARTICIPATION IN THE INSURANCE PLACEMENT. Notice to the Proposer/Assured. The Parties are free to choose the law applicable to this insurance contract. Unless specifically agreed to the contrary this insurance shall be subject to English Law. Any enquiry or complaint should be addressed in the first instance to your Broker. If you are not satisfied with the way a complaint has been dealt with you may ask the Complaints and Advisory Department at Lloyd s to review your case without prejudice to your rights in law. The address is: Complaints Department Lloyd s, One Lime Street, LONDON EC3M 7HA Telephone: LSW 1002 (02/99) (amended).

3 Please complete this Proposal form in BLOCK CAPITALS to avoid problems when transmitting by fax. For any additional information, or information that you cannot fit into the spaces provided, please use a separate sheet. 1) Please state: Name of the Charity/Association Address Postcode Establishment date Charity number Website Address: Address: 2) Please state type of Charity (e.g.trust, Limited Liability Company, Industrial/Provident Society, Unincorporated Association/Trust, Incorporated by Royal Charter) 3) Please state total number of: Qualified staff All other staff Voluntary staff engaged in charitable work other than fund raising 4) Please supply full details of all persons acting as Governors,Trustees, Directors of the Company and/or Officers of the Charity: Name Position Date commenced Occupation 5) Please state the activities/purpose of the Charity/Association: 6) Do the Charity/Association s activities/purpose extend overseas? If, please state where and in what manner: 1

4 7) How are investments managed? External professional managers Directly by the Trustees 8) Has the Charity/Association changed any of its professional advisers in the past three years? If, please provide full details: 9) (a) Are written references obtained in respect of employees responsible for the handling of monies? (b) Has the Charity/Association suffered any loss during the past five years through fraud or dishonesty of any employee? If, please provide full details including dates, circumstances and steps taken to prevent a recurrence: (c) Is any employee allowed to sign cheques on his/her signature alone? If, up to what amount? (d) Are cash books, receipts, counterfoils and bank statements checked independently by a Governor/Trustee/Director/Officer at least monthly? 10) (a) Have any complaints concerning the Charity/Association been made to the Charity Commissioners? If, please provide details: 2

5 (b) Has the Charity/Association ever been, or is it currently, subject to an investigation by the Charity Commissioners or any other official Body or Institution? If, please provide details: 11) Has Trustee liability insurance been carried during the last year? If, please state: Name of Insurers Name of Broker Renewal Date Limit of Indemnity Premium Excess 12) Please state limit of indemnity required: 13) (a) In respect of ANY of the risks to which this proposal relates, has any Claim been made (whether successful or not) against the Charity/Association, any predecessor or any past or present Trustee or person stated in Question 4 of this Proposal? (b) Has any loss been suffered by the Charity/Association, any predecessor or any past or present Trustee or person stated in Question 4 of this Proposal in respect of ANY of the risks to which this proposal relates? If, please give details: Date of Brief details of each claim/loss Cost of Estimated cost claim/loss claim/loss of claim/loss outstanding 3

6 (c) What steps have been taken to prevent a recurrence? 14) Is any Trustee or person stated in Question 4 of this Proposal, AFTER FULL ENQUIRY, aware of any circumstance which might: (i) Give rise to a claim against or cause any loss to the Charity/Association, any predecessor or any past or present Trustee or person stated in Question 4 of this Proposal? (ii) Has any proposal for similar insurance made on behalf of the Charity/Association, any predecessor or any past or present Trustee or person stated in Question 4 of this Proposal ever been declined or has any such insurance ever been cancelled or renewal refused? (iii) Otherwise affect the consideration of this proposal for insurance? If, to any of the above, please give details: Please read this paragraph carefully before signing the declaration: It is essential that you, when seeking a quotation to take out or renew any insurance, disclose to the prospective Underwriters 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. Failure to do so entitles the Underwriters, if they so wish, to avoid the contract of insurance from inception and so enables them to repudiate liability thereunder. If you have any doubt as to what constitutes a material fact or circumstance please do not hesitate to ask for advice. DECLARATION I/we declare that, after full enquiry, the contents of this proposal are true and that I/we have not misstated, omitted or suppressed 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. If there is any material alteration to the facts and information which I/we have provided or any new material matter arises before the completion of the contract of insurance, I/we undertake to inform Underwriters. I/we hereby consent to any information I/we have provided being processed by you for the purposes of providing insurance and claims handling, which may necessitate sharing such information with third parties. Dickson Manchester & Company Ltd may use this information for marketing (by post, telephone, or fax) subject to the conditions of the Data Protection Act. If you do not wish these details to be used for marketing please inform Dickson Manchester & Company Ltd in writing. Under the Data Protection Act 1998 you have the right to access or amend the information we hold about you. If you would like to exercise either of these rights please contact Dickson Manchester & Company Ltd. Date: Signature of Governor/ Trustee/Director/Officer: A COPY OF YOUR LAST YEARS ACCOUNTS MUST BE SUBMITTED WITH THIS PROPOSAL FORM All questions must be answered fully, and those questions not relevant to you should be marked accordingly. If there is insufficient space, please provide details on your letterhead. A copy of this Proposal should be retained by you for your own records 4

7 Do you wish to pay your premium by instalments? PREMIUM LOAN PLAN If, it may be possible to use the facility that we have arranged with Premium Credit Limited, a long provider of insurance premium finance, which provides a scheme to allow you to spread the cost of our PI premium over 10 equal monthly instalments. The monthly cost is normally per 1,000 of premium, commencing one month after inception/renewal. The rate may change if interest rates move a lot. The precise rate will be confirmed on loan documentation before you are committed. To take advantage of this option simply complete the following questionnaire. Upon approval by Premium Credit Ltd you will be sent a simple form of loan agreement for completion and signature, which will also set out the complete terms of the loan. Immediately return this, together with your first instalment, to Premium Credit Ltd who will then settle the premium on your behalf.the minimum premium for this facility is 500 and the minimum charge for credit Contact Name Name of Firm Address Postcode Tel Fax Type of Business Registered No Date Established Gross Fees Bank Details Name of Bank Address Account No Sort Code We authorise Dickson Manchester and Company Ltd to disclose to you any information which you may consider necessary for evaluating this request for credit including any information from our current insurance proposal form.we warrant that the information contained in that proposal form is correct. Has the Applicant or any Director/Partner of the Applicant been the subject of litigation in respect of an unsatisfied debt(s)? If, please supply further details. Signed: Date: Office Use Only Ref... R/D... Premium... Cont... (including IPT and DM Fee if applicable) 5

8 DICKSON MANCHESTER & COMPANY LIMITED Walsingham House 35 Seething Lane London EC3N 4AH Telephone: Facsimile: Web:

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