Our head office and registered address is: Sportsguard One Overstone Heights, Sywell, Northamptonshire, NN6 0AT

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1 Public Liability proposal form Our head office and registered address is: Sportsguard One Overstone Heights, Sywell, Northamptonshire, NN6 0AT Sportsguard is a trading and product name of The Admin Bureau Ltd. Authorised and regulated by the Financial Conduct Authority. Please read: For teams & clubs public liability insurance, complete sections A, B, C, D (if applicable), E, F and read G For coaching schools liability insurance or coaches liability, complete sections A, B, C, D, E, F and read G Section A Proposer details Contact name Company name/group name Trading style Is the Company/Group incorporated i.e. Limited Company, Charity... (if yes, give company registration number) Full Postal Address Telephone Numbers Address Fax Number Postcode Home Work Mobile Activity details Sports you wish to insure How many games/sessions per week Age of participants Do you always use the same venue? Section B On average (if yes, give full details below) Full name of the Venue Full Address Postcode Period of insurance required From / / To / / Are you insured at present? (if yes, give last years premium below) Last years insurance cost

2 To be completed for public liability cover Have a written procedure/official designated for: Does the applicant: Section C Risk management Alcohol service Blood spillage Administering first aid Keeping an accident report book Own the premises? (if yes, give details below) Have building liability insurance? (if yes, give details below) Hire out those premises to others? (if yes, give details below) Do hiring parties have their own insurance? (if yes, give details below) Operate licensed premises? (if yes, give details below) Sell goods to the public? (if yes, give details below) Have a grandstand at the premises? (if yes, give details below) Number of registered members i.e. Committee members, etc... Number of participating players Number of registered officials i.e. Secretary, treasurer etc... Number of registered coaches Please attached a list of ALL registered coaches along with their full address and any coaching qualifications Do you run the group as a business? (if yes, give your estimated turnover details below) Duration of season How many games/sessions per season Name of your affiliating governing body Limit of indemnity required i.e. The FA 1 Millionq 2 Millionq 5 Millionq 10 Millionq

3 To be completed for employers liability cover Are the premises maintained to a good standard? Section D (please, give details below of the maintenance programme) Are all regulations for the maintenance & safety of your equipment complied with? Are any hazardous substances used and/or stored? (if yes, give details below of handling and storage procedures) Do you have any mobile plant &/or vehicles not licensed for road use? (if yes, give details below of type, handling, storage and security) Cover & Limits Provide the current wage roll details for each of the following duties Duties Wage Roll Clerical Managerial (excluding manual activities) Retail/catering/bar staff Players/participants Coaches/instructors Ground maintenance Woodworking Other manual* *please provide details Do you contract work to any labour only subcontractor or bona fide sub-contractor (if yes, give details below) Previous Claims History Section E Provide details of all claims for incidents during the last 5 years (note: confirmed claims history from previous insurers can be requested at any time to validate your answers) Type Date Incident description Paid Outstanding Has any action been taken to prevent a reoccurrence?

4 Section F Declaration Has your business: had any insurance proposal or renewal declined, cancelled or withdrawn? or any of it s principals, partners or directors had any prosecutions of summonses served? Have you or any director, partner or principal ever: Been declared bankrupt or insolvent? Been subject to any county court judgements? Been convicted or charges with any criminal offence, other than driving offences? If yes to any of the above, please provide details: 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 provide details: Please read the declaration carefully and then sign below. I/we understand that if true answers have not been given that this insurance may not protect me/us in the event of a claim. I/we declare that the answers given to questions asked in this proposal are true and complete to the best of my knowledge and belief. I/we understand that any material fact, which is information that may influence the underwriter(s) in the acceptance and terms provided, has been disclosed and recorded. I/we understand that non-disclosure or misrepresentation of material facts will entitle underwriters to void the contract. I/we understand that the signing of this proposal form does not bind me/us to complete the insurance contract. However, I/we agree that should a contract of insurance be completed, then this questionnaire and the declaration made herein shall form an integral part towards the basis of contract. I/we understand that any change in information must be notified immediately and no cover exists until such change has been approved by underwriters. Data Protection I/we understand that to sep up and administer your insurance, Sportsguard will hold and use information including sensitive personal information (which may include things such as criminal convictions and health information) about you supplied by you. Information may be passed to underwriters and agents for my insurance. This includes underwriting, processing, claims handling and preventing fraud, and could include passing information to reinsurers, other insurers and subcontractors in the United Kingdom or any other country (even those which have limited Data Protection Laws) Signed Position Date

5 Important Information Section G It is of vital importance that all organisations protect themselves against the disastrous consequences of liability for injury or damage arising out of their actions and this includes the actions of all-executive officials, members and volunteers. Such officials and members at all levels could find themselves held personally responsible for court costs and damages awarded where an action has been brought against the club for negligence and it is essential that adequate liability cover is arranged to avoid such consequences. The main features of the policy are summarised below. Public Liability Bodily injury to third parties and/or damage to third party property arising out of the insured activities. Cover includes member-to-member liability, damage to leased or rented premises, trespass, nuisance and pollution. The interest of principals (land/property owners etc.) is also included. Professional Indemnity Loss (financial or otherwise) that arises out of Errors and Omissions (e.g. bad advice or failure to act). Liability arising out of Libel & Slander. Products Liability Bodily injury to third parties and/or damage to third party property arising out of any goods sold or supplied by the Insured. Abuse Damages and associated legal costs following claims for injury caused by acts of abuse. (this cover may be subject to an additional questionnaire). Limit of Indemnity The Limit of Indemnity under the policy can be chosen at 1 Million, 2 Million, 5 Million or 10 Million. Basis of Cover Civil Liability cover is provided on a Claims Made basis unlike other forms of cover, there has to be a policy in force at the time which the claim is made against you, not necessarily at the time the activity was undertaken. Once a policy is cancelled, no cover would be provided for any claim that arose after the date of cancellation. Please return your completed proposal form to: Sportsguard, One Overstone Heights, Sywell, Northamptonshire, NN6 0AT The Admin Bureau Ltd 2014

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