CONSTRUCTION INDUSTRY COMBINED INSURANCE. standards. redefining. Proposal Form August 2013 Edition

Transcription

1 CONSTRUCTION INDUSTRY COMBINED INSURANCE Proposal Form August 2013 Edition redefining standards

2 Important tice To apply for the Construction Industry Combined Insurance Policy, complete this Proposal Form in BLOCK CAPITALS using a ball-point pen (blue or black ink). Insurance begins when AXA Insurance has accepted your application. You must give full and true answers to all questions. If you do not do so your insurance cover may not protect you in the event of a claim. You should keep a record of all information supplied to AXA Insurance (including copies of correspondence). Correct values at risk must be advised to us. If the Sums Insured you request are not adequate this will result in the amount that we pay you in the event of a claim being reduced. If the space provided is inadequate or you tick a shaded box please supply full details using the Additional Information Section. A copy of this Proposal can be supplied on request, within a period of 3 months after its completion. A copy of the Policy is available on request. AXA Insurance UK plc is authorised and regulated by the Financial Services Authority. Law Applicable to Contract You and we can choose the law which applies to this policy. We propose that the Law of England and Wales apply. Unless we and you agree otherwise, the Law of England and Wales will apply to this policy. PART A - Your Business Details Insured Full names (Please give full names of partners if not a Limited Company) Trading name (if different from name above) Trade or Business Postal Address Postcode Daytime Telephone. Contact name and position within company Do you wish to pay the premium by instalments? If please complete a Budget Plan Application Please detail membership of any Industry, Trade or accreditation body Operative Date Cover required from Renewal Date (DD/MM/YYYY) (DD/MM/YYYY) The liability of AXA Insurance does not commence until acceptance of the Proposal has been confirmed by AXA Insurance. 2

3 General Questions If you tick a shaded box 3 please give details. If the space provided is inadequate, use the Additional Information section or continue on separate sheet(s). 1. Are any additional interests to be endorsed on the Policy, e.g. Bank? If please provide name, address and postcode 2. How long have you been in business: a) at the premises to be insured? Years b) at any other premises? Years 3. Are you the sole occupier of the premises? 4. Are the premises in good repair internally and externally and will they be so maintained? 5. Have you or any of your partners or directors either personally or in connection with any business in which you have been involved a) previously held insurance for any of the covers to which this Proposal relates at these premises or elsewhere? If please advise name of Insurers and Policy number b) held any insurances (in respect of the covers to which this Proposal relates) which have subsequently been i) declined? ii) terminated? iii) refused renewal? iv) subject to special terms? c) ever been convicted or charged (but not yet tried) with a criminal offence other than a motoring offence? d) ever been declared bankrupt or are the subject of any current bankruptcy proceedings or any voluntary or mandatory insolvency or winding up procedures? e) ever been the subject of a recovery action by Customs and Excise or the Inland Revenue? f) had within the last five years any losses whether insured or not or had any claims made against you (in this or any existing or previous business)? If please complete the claims experience box opposite 3

4 6. Are there any other material facts you should disclose? A material fact is information that may influence the Company in the acceptance of this insurance and the terms provided 4

5 Claim Experience Please detail below any losses within the last five years whether insured or not in respect of any of the covers to be insured under this policy. Date of Occurrence Claim Type (See below) Brief details of each incident (Whether a claim was made or not) Cost Paid or outstanding Claim Type codes MDI = Material Damage THE = Theft CAR = Contractors All Risk BII = Business Interruption ELI = Employers Liability PLI = Public Liability MON = Money SAR = All Risks GIT = Goods in Transit 5

6 PART B - Cover options Property Basis of Cover - please refer to Policy Summary of Cover. Under this Section you should select the cover you require by ticking the appropriate boxes below. Cover Required 1. All Risks or 2. Specified Perils te If you have selected specified perils, please tick the appropriate boxes to indicate cover required i) Cover for malicious damage will only be considered where riot cover is also requested Storm Escape of water Aircraft Malicious damage Earthquake/subterranean fire Flood Explosion Riot Impact Sprinkler leakage ii) Cover for flood will only be considered where storm cover is also requested 3. Theft following entry to or exit from the premises by forcible and violent means 4. Do you require the Day One Average extension? If, please tick the inflation percentage required +15% +20% +25% +30% +50% Sum Insured Please make sure your Sums Insured allow for: Buildings Landlords fixtures and fittings Architects surveyors legal and consulting engineers fees Outbuildings Walls gates and fences Yards car parks and pavements Piping ducting cables wires and associated control gear on the premises extending to the public main but only to the extent of your responsibility Fixed glass Debris removal costs Contents Machinery and plant Legal and consulting engineers fees Property held in trust Tenants improvements Debris removal costs Contents of outbuildings Contents of open yards Stock and Materials in Trade Property held in trust Debris removal costs Theft is not covered } Reinstatement Value The sum insured under the Buildings and Contents should represent the reinstatement value as losses will be settled on this basis unless we advise you to the contrary on acceptance of this proposal. 6

7 Section 1 - Material Damage Basis of Cover - please refer to Policy Summary of Cover. Premises And Sums To Be Insured Standard construction means premises built of brick stone or concrete and roofed with slates tiles concrete metal asbestos or sheets or slabs composed entirely of incombustible mineral ingredients and plastic roof lights 1. Premises Insured Postcode Phone Number (if different from that provided under Your Business Details) 2. Sums Insured a) Buildings b) Contents c) Stock d) Other Property (please specify) 3. Occupation How do you occupy the premises? (tick as appropriate) Factory Warehouse Office Other - please specify 4. Construction a) Are the premises of standard construction? b) If are the premises lined with combustible wall linings or sandwich panels? If please advise details c) If to a) and b) please give details 5. Heating Please state method of heating premises 7

8 6. Are the premises in a position or area likely to be subject to flooding or where flooding has occurred? 7. Has the electrical installation been inspected by a qualified engineer during the past 5 years? 8. Are you the sole occupier of the premises? 9. Do you wish to extend your cover to include Subsidence? If a) Has the property or any adjacent property previously suffered damage from subsidence? b) Are there visible signs of cracking? c) Is the property erected on made up ground? d) Are there any trees within 5 metres of the premises? e) Are there any elm, poplar or willow trees within 10 metres of the property? If a structural survey has recently been carried out please attach a copy 10. Additional Premises Are any additional Premises to be insured? If, please complete additional premises information sheet(s) 8

9 Section 2 - Theft Basis of Cover - please refer to Policy Summary of Cover. Premises And Sums To Be Insured 1. Premises Insured The cover will apply to the same addresses as those listed in the Material Damage Section 2. Sums Insured a) Contents (excluding property in b) c) d) and e) below) b) Stock c) Portable tools d) Electronic office equipment (i.e. computers and peripheral equipment, fax machines, photocopiers and word processors) Are any items included under d) valued in excess of 5,000? If please list these with values on page 22 e) Other Property (please specify) 3. Are the premises protected by an intruder alarm? If a) Name of installer b) Method of signalling Bells only Digital communicator BT Redcare Other - Please specify 4. Additional Premises Are any additional Premises to be insured? If, please complete additional premises information sheet(s) 9

10 Section 3 - Contractors All Risks Basis of Cover - please refer to Policy Summary of Cover. Turnover - Sums To Be Insured 1. Turnover Please state the estimated turnover in the next 12 months for a) Construction of private dwellings, shops, offices and/or hotels consisting of not more than two floors (including ground floor) and attic and single storey buildings not exceeding 8 metres in height b) All other work please describe nature of work 2. Sums Insured a) Maximum value any one Contract b) Own plant and equipment (Please list with their values on page 22) c) Temporary buildings or other temporary works d) Hired in plant, if cover required please state i) Model Conditions used e.g. CPA HAE Other (give details below) ii) Estimated annual hiring charges iii) Maximum value any one item e) Employees tools and personal effects 10

11 Details 1. What Conditions of Contract are usually used? 2. Will work be done where there is no principal? e.g. Speculative buildings If, what is the percentage in relation to your annual turnover? % of turnover 3. For builders only: What is the maximum value of any one building or range of buildings under one roof? 4. Do you propose to undertake contracts which involve a) buildings of non standard construction (ie not built of brick, stone or concrete and not roofed with slates, tiles, concrete, metal, asbestos or sheets composed entirely of incombustible mineral ingredients and plastic roof lights)? b) demolition or shoring-up? c) local authority work? d) work in, under or over water or adjoining or adjacent to rivers, lakes, reservoirs, dams or within coffer dams or caissons? e) work on bridges, viaducts or tunnels? f) work on motorways, dams or nuclear installations? If you have ticked a shaded box 3 please give details. 11

12 Section 4 - Business Interruption and Accounts Receivable Basis of Cover - please refer to Policy Summary of Cover. Premises And Sums To Be Insured 1. Premises Insured The cover will apply to the same addresses as those listed in the Material Damage Section 2. Sum Insured a) Estimated Gross Profit b) Additional Expenses only (minimum 10,000) c) Accounts Receivable 3. Uninsured Working Expenses Please list the expenses you are not insuring under item 2a): bad debts purchases and 4. Maximum Indemnity Period (only required for item 2a) Please state Maximum Indemnity Period required months (min 12 months) Where the indemnity period exceeds 12 months the sum insured should be increased proportionately. The Optional Extensions Listed Below Are Available If you answer to questions 1 & 3 please give full name and address including postcode Cover Required 1. Suppliers premises % of Estimated Gross Profit Postcode 2. Premises where contracts are carried out in Great Britain 3. Premises (other than your own) where property is stored % of Estimated Gross Profit % of Estimated Gross Profit Postcode 4. Premises of any public supply undertaking from which you obtain electricity, gas, water, or telecommunications services 5. Goods in transit 6. Motor vehicles 7. Do you wish to cover loss resulting from theft or attempt thereat? % of Estimated Gross Profit % of Estimated Gross Profit % of Estimated Gross Profit 12

13 Section 5 - All Risks - Selected Articles Basis of Cover - please refer to Policy Summary of Cover. Details of Articles to be Insured Sum Insured Please indicate cover required by ticking box 1, 2, 3 or 4 1 Europe 2 Great Britain 3 Insured premises only 4 Worldwide 13

14 Section 6 - Money Basis of Cover - please refer to Policy Summary of Cover. Limits For any loss of Money (other than crossed cheques and cancelled National Insurance stamps) Limits Required 1. In transit or in a bank night safe or from the premises during Business Hours 2. From the premises out of Business Hours in the undernoted locked safe or strongrooms Show makers name and model number 3. From the premises out of Business Hours or at the residence of any principal or authorised employee 500 maximum per premises Maximum amount of money carried by one person Estimates 1. Estimated annual amount of notes and coins in transit 2. Does the above include money relating to all your premises? If the answer is please specify why Personal Accident - Assault Do you wish to increase the benefits from 5,000 (capital sums) and 50 (per week)? If the answer is, please state limits required (maximum 10,000 capital sums and 100 per week) 1. Capital sums 2. Temporary total disablement (weekly benefit) 14

15 General Questions 1. Give full details of precautions taken for the safety of the money a) at the premises or sites (excluding money in a locked safe) b) in transit 2. Will the money be in the possession of collectors or roundsmen? If the answer is, please state the maximum amount held Liability Basis of Cover - please refer to Policy Summary of Cover. Please tick appropriate box to indicate the cover required LIMIT OF INDEMNITY Employers Liability 10,000,000 Do you wish us to consider a higher amount? If please specify amount Public Liability Please specify amount required Your Business Please give details of work undertaken 15

16 Section 7 - Employers Liability Basis of Cover - please refer to Policy Summary of Cover. Estimates Please give details of your estimated turnover, wages and other payments for the next 12 months. Wageroll of All Your Employees (which include labour masters, labour only persons or persons supplied by them, self employed persons or persons hired or borrowed) 1. Clerical staff (including commercial travellers and managerial employees who do not engage in manual labour) 2. Woodworking machinists and their labourers Employers whose work with woodworking machinery is restricted to the use of lathes, fret-saws, boring machines, sanding machines and mechanically-driven portable hand tools (other than pendulum and swing saws) may be included under Other building work 3. Building employees engaged in a) Construction of private dwellings, shops, offices, public houses and/or hotels consisting of not more than two floors (including ground floor) and attic and/or single storey buildings not exceeding 8 metres in height b) Alteration, maintenance or repair of private dwellings, shops, offices, public houses and/or hotels consisting of not more than four floors (including ground floor) and attic and/or single storey buildings not exceeding 8 metres in height c) Other building work (please describe) 4. All other trades (please describe) 16

17 Section 8 - Public Liability Basis of Cover - please refer to Policy Summary of Cover. 1. Wageroll of all Employees (which include labour masters, labour only persons or persons supplied by them, self employed persons or persons hired or borrowed) and Working Principals in respect of a) Construction of private dwellings, shops, offices, public houses and/or hotels consisting of not more than two floors (including ground floor) and attic and/or single storey buildings not exceeding 8 metres in height b) Alteration, maintenance or repair of private dwellings, shops, offices, public houses and/or hotels consisting of not more than four floors (including ground floor) and attic and/or single storey buildings not exceeding 8 metres in height c) Other building work (please describe) d) All other trades (please describe) 2. Estimated payments to sub-contractors who provide both labour and materials in respect of work described in a) question 1a) above b) question 1a) above c) question 1c) above d) question 1d) above 3. Do you Hire in or Hire out plant and/or equipment? If, please provide estimated charges below a) Hired in b) Hired out 4. Do you sell goods from a shop or warehouse? If, please state the approximate turnover 5. Do you or any of your employees undertake certification work under the Housing and Building Control Act? 17

18 General Questions 1. Do you handle, use, store or transport any of the following: a) asbestos or silica or materials containing these substances? b) dioxins? c) isocyanates? d) radioactive substances or other sources of ionising radiations? e) acids, gases, chemicals, explosives or other toxic, dangerous or waste substances? 2. Are your premises in a good state of repair? 3. Is your machinery and plant (including mechanically propelled plant) properly fenced, guarded and in good order and where appropriate inspected in accordance with statutory requirements? 4. Do you have a written Health and Safety Policy in place, which is regularly updated and are all employees aware of its content? 5. Are you aware of the requirements of the Health and Safety at Work etc Act 1974 and do you complete workplace risk assessments in accordance with Section 3 of the Health and Safety at Work regulations 1999? 6. Are all recommendations made by the Factory Inspector or any other similar authority carried out? 7. Has any prosecution, prohibition notice or improvement order been made against you under any Health and Safety legislation during the last 5 years? 8. Are chemicals, effluent fumes or anything of a noxious nature discharged from your premises? If, please state what arrangements exist to render harmless such discharge 9. Do you work on or in aircraft operational areas, waterborne craft, offshore nuclear installations, petro-chemical works or power stations? 10. Do you use oxy-acetylene or similar welding or cutting equipment, angle grinders, blow lamps blow torches, flame guns, hot air guns or other heat producing equipment? If, complete a) and b) below a) at own premises b) away from own premises Nature of Use Annual Wage Roll 18

19 11. Do you undertake a) demolition contracts? b) construction, alteration or repair of towers, steeples, chimney shafts, viaducts, bridges, docks or tunnels? c) piling or the use of explosives? d) water diversion, dam construction or work within or behind dams? 12. Will you undertake any manual work outside the United Kingdom? 13. Do you enter into any contracts or agreements which may affect your liability under Statute or Common Law? If, please give details including copies of the contracts/agreements If you have ticked a shaded box 3 please give details below 14. Do you enter into any Design and Build contracts or other contracts imposing a professional duty upon your firm or others whom you may appoint on a sub-contract basis in connection with the contract? 15. Do you own or operate any quarry or waste disposal site? 16. a) Do you own or are you responsible for lifts, cranes, hoists or other lifting apparatus? b) Is the above plant inspected in accordance with Statutory requirements? c) Are any defects revealed promptly remedied? If you have ticked a shaded box 3 please give details below 19

20 Section 9 - Goods In Transit Basis of Cover - please refer to Policy Summary of Cover. Own Vehicles Reg. Details Make of Vehicle Type of body. of trailers per vehicle Sum insured per trailer 1. Type of property carried 2. Maximum number of vehicles used to carry goods at any one time 3. Are the vehicles used in conjunction with a) soliciting of orders? b) commercial travelling? 4. a) Are any of your vehicles left loaded and unattended at night? If the answer is, what arrangements do you make for their garaging and safe custody? b) Do you have permanent garage premises? If, what is the full address? Postcode 5. a) Are your vehicles fitted with i) immobilising devices? ii) any locks additional to those provided by the manufacturers? iii) an alarm system? b) If the answer to 5a), (i), (ii) or (iii) is please provide details c) Are these devices put into operation whenever the vehicle(s) is (are) left unattended? d) Is the alarm subject to a maintenance contract? If, by whom? 20

21 Section 10 - Terrorism Do you require this cover under 1. Material Damage and where operative the All Risks - Selected Articles and Contractors All Risks Sections? 2. Business Interruption and Accounts Receivable additionally? Section 11 - Engineering Basis of Cover - please refer to Policy Summary of Cover. Do you require any of the following Engineering insurance covers? Sudden and Unforseen damage Computer Cover Machinery Movement Contractors Plant and Equipment Deterioration of Stock Engineering Business Interruption 21

22 Section 12 - Additional Information 22

23 PART C - Declaration If you have not given full and true answers to all questions asked on this Proposal, your insurance may not protect you in the event of a claim. If you wish to disclose something that has not been disclosed elsewhere in this Proposal, please use the box provided here. Before signing the Declaration, please read the notices on this page about the Claims and Underwriting Exchange Register and Data Protection Act. Claims and Underwriting Exchange Register Insurers pass information to the Claims and Underwriting Exchange Register run by Insurance Database Services Limited (IDS Ltd). The aim is to help us check information provided and also to prevent fraudulent claims. When we deal with your request for insurance we may search the register. When you tell us about an incident (such as fire, water damage or theft) which may or may not give rise to a claim, we will pass information relating to it to the register. You can ask us for more information about this. You should show this notice to anyone who has an interest in property insured under this policy. Data Protection Act AXA Insurance UK plc is a member of the AXA Group. To set up and administer your policy we will hold and use information including sensitive personal information (sensitive personal information may include such things as criminal convictions and health information) about you supplied by you. We may send it in confidence for processing to other companies in the AXA Group (or companies acting on our instructions) including those located outside the European Economic Area. By signing this form you consent to such use of your personal data including any sensitive personal data. AXA Insurance UK plc may send you details of our other products and services. To enable them to send you details of their products and services, we may also share your name and address with: other AXA companies within the European Economic Area other carefully selected companies outside the AXA Group. You may be contacted in writing or by telephone or fax. If you do not wish to receive such details please tick the appropriate box(es). Declaration I/We declare that the answers given to questions asked in this proposal are true and complete to the best of my/our knowledge and belief. I/We understand that any material fact, which is information that may influence the Company in the acceptance of this insurance and the terms provided, has been disclosed and recorded. I/We understand that if I/we have not given full and true answers to all questions asked on this proposal that my/our insurance may not protect me/ us in the event of a claim. I/We understand that you will pass the information on this form and about any incident I/we may give details of to IDS Ltd so that they can make it available to other insurers. I/We also understand that, in response to any searches you may make in connection with this application or any incident I/ we have given details of, IDS Ltd may pass you information that it has received from other insurers involving anyone insured under the Policy. I/We agree to accept the terms and conditions contained in the AXA Insurance UK plc Policy applying to this proposal. Signature of Proposer Name Position in Company Date (DD/MM/YYYY) cover is in force until the Proposal has been accepted by AXA Insurance UK plc. 23

24 AXA is a world leader in wealth management and financial protection. We operate in over 50 countries and serve more than 50 million customers worldwide. We cater to a wide range of needs, providing advice and guidance to our individual and corporate customers on a variety of financial products and services. In addition to Business, Motor and Home Insurance we also offer Investments, Life Assurance, Retirement Planning, Long Term Care, Asset Management, Medical Insurance and Dental Payment Plans. With our expertise and commitment to customer service and consistent, quality care, you can rely on AXA for lasting security. Ask about AXA s excellent range of business, Home and Motor Insurance Products WCB016R/X-A (08/13) (34794) AXA Insurance UK plc Registered in England Registered Office: 5 Old Broad Street, London EC2N 1AD. A member of the AXA Group of Companies. AXA Insurance UK plc is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Telephone calls may be monitored or recorded. redefining standards