Duplicate forms & other stationery are available from our website
|
|
|
- Bernice Gabriella Skinner
- 10 years ago
- Views:
Transcription
1 As you are no doubt aware, the above policy falls due for renewal on. To enable us to calculate renewal terms, please complete and return the attached Declaration, Estimate and Renewal Questionnaire. Should any amendment to policy cover or a higher limit of indemnity is required, please advise us. Any fact which materially alters the risk must also be disclosed if in doubt please advise the fact. The policy will automatically include free Professional Indemnity cover with a limit of 100,000 subject to the percentage of turnover relating to Specified Professional Activities being less than 10% of the overall turnover. Please refer to the question on the attached Renewal Questionnaire. Higher limits are available on request. Where Professional Indemnity insurance with a limit in excess of 100,000 is currently provided, insurers will require a freshly completed proposal form in order to invite renewal. A copy will be issued to you shortly but if you wish to obtain this form now, please visit our website Where the policy includes Commercial All Risks, Business Interruption or Contract Works, please can you advise us of any alterations required to the sums insured or limits. Where Contract Works is included, please can you also confirm the total hiring charges for hired in plant, if cover is applicable. Renewal terms will be provided 21 days prior to the renewal date subject to the receipt of the fully completed estimate form no less than 28 days prior to the renewal date Duplicate forms & other stationery are available from our website We look forward to receiving your advices prior to the expiry of the policy to ensure continuity of cover. Please note that no extensions of cover are available beyond the renewal date and cover will cease if instructions have not been received.. Yours sincerely Sutton Specialist Risks Ltd Please note all calls are recorded for monitoring and training purposes
2 DECLARATION FORM Period to QBE Insurance Combined Policy No: Type of Work Clerical or managerial (non manual) Solar Photovoltaic (PV) Directors, principals & partners wages ( ) Below Own employees and labour only sub contractors wages ( ) Below Bona Fide Sub Contractors payments ( ) Turnover Solar Thermal heating (domestic) Wind Energy/Turbines Home Insulation Heating (all other than domestic) Biomass Micro - Hydro Micro CHP Rainwater Harvesting Any other work (please also advise what activity this relates to)
3 ESTIMATE FORM Period to QBE Insurance Combined Policy No: {Policy Number: Type of Work Clerical or managerial (non manual) Solar Photovoltaic (PV) Directors, principals & partners wages ( ) Below Own employees and labour only sub contractors wages ( ) Below Bona Fide Sub Contractors payments ( ) Turnover Solar Thermal heating (domestic) Wind Energy/Turbines Home Insulation Heating (all other than domestic) Biomass Micro - Hydro Micro CHP Rainwater Harvesting Any other work (please also advise what activity this relates to)
4 QBE Insurance Combined Policy No: RENEWAL QUESTIONNAIRE Are you a member of any Regulatory Body or Trade Association Are you accredited or registered with an Approvals or Certification Body in respect of the work undertaken If YES please give details below including membership number YES NO Do you have ISO 9001 Accreditation Do you have Safe Contractor Accreditation Do you have less than 10 employees Do you undertake work (or supply goods) which: Involves the use of LPG Blow lamps, LPG cutting equipment, Oxy-acetylene, Arc, MIG and TIG welding (away from your own premises) Is on board ships, on off-shore installations, at airports, chemical or petrochemical works, nuclear installations, bulk oil or gas storage facilities, on or alongside railway tracks. Is outside Great Britain Is in Northern Ireland Is at a height in excess of 16 metres using slings/cradles/abseiling or rope access methods At a depth exceeding 2 metres If you have answered YES to any of these questions, please provide full details including turnover & wages estimates for these activities. NOTE: The policy will automatically include free Professional Indemnity Insurance (subject to completed Declaration Form) with a limit of indemnity of 100,000, provided less than 10% of the turnover is from Specified Professional Activities excluding PAT testing (as above). Where this work accounts for more than 10% of the turnover, cover may still be available but we will require a fully completed Professional Indemnity proposal form. Limits over 100,000 are also available but we do also require a fully completed Professional Indemnity proposal form to quote. See
5 Employers Reference Number QBE Insurance Combined Policy No: Where we provide an indemnity under the Employers Liability Section, from the 1 st April 2012, we are required by regulation to maintain a database of all the companies and subsidiary companies covered and provide details of all company names to the Employers Liability Tracing Office Database. In order to prepare for the new regulation, we are now collecting this information in readiness. Note: It is a condition of this insurance that you undertake to supply full details (as required by the Employers Liability Tracing Office) of the company and all subsidiary companies with their Employers Reference Numbers. Please provide the information requested below: Insured Company Names (including Subsidiaries) Employers Reference Number (ERN) General Definition: Employers Reference Number (ERN) An ERN (also known as an employer PAYE reference) is given to every business that registers with HM Revenue and Customs as an employer. This reference is made up of two parts: a three-digit HMRC office number and a reference number unique to your business. It will be appears on your correspondence with HMRC.
Tradesman & Contractors Policy Statement Of Facts
This Statement of Facts was issued on 03/08/2015 14:46:23 Your iprism reference is Your Policy Number is 0000RLSY I11/052014/TR/013442 Your insurance is effective from 03/08/2015 13:06:11 Agency Agent
Liability & Construction Construction Quote Form
Liability & Construction Construction Quote Form www.towergate.co.uk/liabilityconstruction Towergate Underwriting Liability and Construction are able to provide cover for general liability and contractors
CAMBERFORD LAW PLC ELECTRICAL, HEATING, VENTILATION, PLUMBING AND AIR CONDITIONING CONTRACTORS INSURANCE PROPOSAL FORM
CAMBERFORD LAW PLC ELECTRICAL, HEATING, VENTILATION, PLUMBING AND AIR CONDITIONING CONTRACTORS INSURANCE PROPOSAL FORM Please note that 'You' or 'Your' in the context of this Proposal Form means the persons
Rail Contractors Liability Insurance
Rail Contractors Liability Insurance (Please ensure that proposal is completed in full and is clear and legible) 1. Applicant Details Full Trading Name: (this should be name required in the policy) Address:
Schedule to the Policy
Schedule to the Policy 1 Policy Number: SALSALIA/R79242/0332/15 2 Form Number: SJC2010SAUA 3 Insured Name: Just Sow Ltd t/a The Hive 4 Insured Address: The Hive, 86-90 Paul Street, London,EC2A 4NE 5 Policy
Combined Liability Roofers and Scaffolders Proposal Form
BDB (UK) Limited 40 Lime Street, London EC3M 7AW Combined Liability Roofers and Scaffolders Proposal Form This proposal form must be completed, signed and dated by a partner, principal or director of the
CONTRACTORS LIABILITY PROPOSAL FORM
CONTRACTORS LIABILITY PROPOSAL FORM Please answer all questions, completing the form in ink using block capitals. The completion and signature of this Proposal does not bind the Proposer or Insurers to
Exclusively Security Proposal
Exclusively Security Proposal The following notes are provided to assist in completion of this proposal form. The Exclusively Security product is our specialist commercial insurance product designed specifically
COMBINED LIABILITY INSURANCE PROPOSAL FORM
COMPANY DETAILS 1. Proposer s Full Name 2. Legal Trading Name (Name to appear on policy documentation) 3. Occupation / Business / Trade Description (please detail all activities) 4. Address Postcode 5.
LIABILITY INSURANCE SUMMARY OF COVER
LIABILITY INSURANCE SUMMARY OF COVER This gives only a summary of the cover provided and it does not give details of all the terms, conditions and exclusions. A full policy wording is available on request.
Effective Date: Expiry Date: STATEMENT OF FACT
Page 1 of 7 Effective Date: Expiry Date: 05/10/2015 at 21:12 04/10/2016 at 23:59 STATEMENT OF FACT Agent: Agency Number: Agent Reference: Insured: Company Status: Address: General Details Your Insurance
S E.L./P.L./C.A.R. INSURANCE APPLICATION FORM C.B.A.I. EMPLOYER S LIABILITY PUBLIC LIABILITY C.A.R. INSURANCE APPLICATION FORM
New RISK MANAGEMENT COMPANY FOR INDEPENDENTS (IRELAND) LTD. Mount Corballis C.4, Rathdrum, Co. Wicklow. Tel.0404 43166 Fax 0404 43167 E mail:[email protected] CONTRACTOR S E.L./P.L./C.A.R. INSURANCE APPLICATION
Please provide details of your claims within the last 5 years Date Incident details Amount paid Amount reserved
Combined Liability Insurance Client name: Operating address: Company reg. number: Business description: Year business established: Current Insurer: Current Broker: Renewal date: Premium: Please provide
CAMBERFORD LAW PLC SCHEME INSURANCE Arboricultural, Horticultural and Landscaping Contractors Enquiry Form
CAMBERFORD LAW PLC SCHEME INSURANCE Arboricultural, Horticultural and Landscaping Contractors Enquiry Form Head Office Lygon House, 50 London Road, Bromley, Kent, BR1 3RA Telephone 020 8315 5000 Website
C.B.A.I. GENERAL EMPLOYER S AND PUBLIC LIABILITY INSURANCE APPLICATION FORM
. New RISK MANAGEMENT COMPANY FOR INDEPENDENTS (IRELAND) LTD. Mount Corballis C.4, Rathdrum, Co. Wicklow Tel. 0404 43166 Fax 0404 43167 E mail [email protected] C.B.A.I. GENERAL EMPLOYER S AND PUBLIC LIABILITY
Professional Indemnity Insurance Proposal Form For The Design and Consulting Departments of Contractors
Professional Indemnity Insurance Proposal Form For The Design and Consulting Departments of Contractors Important Notice 1. This is a proposal for a contract of insurance, in which Proposer or you/your
LIABILITY Fact Finder
LIABILITY Fact Finder When completing this form, please tick the appropriate boxes and answer all questions in BLOCK CAPITALS Important note The information submitted in this form is used by your insurance
Proposal Form - Combined Public and Product Liability Insurance
Toll Free Number 1800-209-5846 (1800-209-LTIN) Website www.ltinsurance.com Proposal Form - Combined Public and Product Liability Insurance SMS LTI to 5607058 (56070LT) GUIDELINES TO FILL THE FORM 1. Please
OPTIMA TRADE PLUS SUMMARY OF COVER
ABC OPTIMA TRADE PLUS SUMMARY OF COVER This document provides a guide to the cover provided. It is however only a summary of the terms of cover and does not contain full details of the insurance policy
Proposal Form - Commercial General Liability Insurance
Toll Free Number 1800-209-5846 (1800-209-LTIN) Website www.ltinsurance.com Proposal Form - Commercial General Liability Insurance SMS LTI to 5607058 (56070LT) GUIDELINES TO FILL THE FORM (Information given
Essential business legal expenses policy schedule
This document is an outline of your cover. It includes your details, details of the business you have insured, the cover given, the cover limits, the excesses and any changes to the standard policy wording
27 February 2012. To Whom It May Concern. Dear Sirs,
27 February 2012 To Whom It May Concern Telephone Fax Website Direct Line E-mail +44(0)113 283 2904 +44(0)113 283 2905 www.willis.com +44(0)113 283 2924 [email protected] Dear Sirs, We act as Insurance
liability insurance application liability Insurer CGU Insurance Limited ABN 27 004 478 371 An IAG Company
liability insurance application liability Insurer CGU Insurance Limited ABN 27 004 478 371 An IAG Company Extract from the Insurance Contracts Act 1984 Under the terms of the Act We must advise You about
W.R. Berkley Insurance Ireland
W.R. Berkley Insurance Ireland ARCHITECTS PROFESSIONAL INDEMNITY PROPOSAL FORM IMPORTANT NOTICE TO THE PROPOSER TO COMPLETION OF THIS PROPOSAL FORM 1) Disclosure - Any material fact must be disclosed to
LIABILITY PROPOSAL FORM BUSINESS LIABILITY COVER
LIABILITY PROPOSAL FORM BUSINESS LIABILITY COVER FOR INTERNAL USE ONLY Agent Name Agency Code When completing this form, please tick the appropriate boxes and answer all questions in BLOCK CAPITALS IMPORTANT
TRADESMEN PROPOSAL FORM
TRADESMEN PROPOSAL FORM FOR INTERNAL USE ONLY Agent Name Agency Code When completing this form, please tick the appropriate boxes and answer all questions in BLOCK CAPITALS IMPORTANT NOTE You (or the broker
Miramar Broadform Liability Insurance Proposal
Miramar Broadform Liability Insurance Proposal IMPORTANT NOTES YOUR DUTY OF DISCLOSURE Before You enter into a contract of general insurance with an insurer, You have a duty, under the Insurance Contracts
PROFESSIONAL INDEMNITY INSURANCE SINGLE PROJECT PROPOSAL FORM
PROFESSIONAL INDEMNITY INSURANCE SINGLE PROJECT PROPOSAL FORM IMPORTANT NOTICE This proposal form must be completed in ink by the Individual or a Partner, Principal or Director of the Firm or Company.
Combined General Liability
Combined General Liability Proposal form Policy number Intermediary Completion notes Please read the following before completing this document. Answer all questions in full. If you need extra space, attach
PUBLIC LIABILITY INSURANCE
Proposal Form PUBLIC LIABILITY INSURANCE ADNIC is a Public Joint Stock Company incorporated in the United Arab Emirates by Law No. (4) of 1972, and it is governed by the provisions of the UAE Federal Law
Design & Construct Professional Indemnity Insurance Proposal Form
Your Professional Indemnity Specialists www.brian-thornhill.co.uk Design & Construct Professional Indemnity Insurance Proposal Form Please complete this form in BLOCK CAPITALS IMPORTANT INFORMATION This
CAMBERFORD LAW PLC. RECRUITMENT AGENCY and EMPLOYMENT BUSINESS INSURANCE PROPOSAL FORM
CAMBERFORD LAW PLC RECRUITMENT AGENCY and EMPLOYMENT BUSINESS INSURANCE PROPOSAL FORM Please note that 'You' or 'Your' in the context of this Enquiry Form means the persons named as Proposer and/or any
CONTENTS CONTENTS STATUTORY MANPOWER & PAYROLL RETURN GUIDANCE NOTES. Introduction... 4. What is an establishment?... 5
CONTENTS STATUTORY MANPOWER & PAYROLL RETURN GUIDANCE NOTES CONTENTS Introduction............................................ 4 What is an establishment?............................... 5 Engineering construction
Fire & Security Policy
NOT INTENDED FOR CUSTOMER USE Fire & Policy Key cover benefits included as standard: Professional Indemnity - 100,000 Fidelity Bonding - Financial Loss (including products) - Vehicle Alarms Service Indemnity
Our head office and registered address is: Sportsguard One Overstone Heights, Sywell, Northamptonshire, NN6 0AT
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
PROFESSIONAL INDEMNITY ENGINEERS & ARCHITECTS PROPOSAL FORM
PROFESSIONAL INDEMNITY ENGINEERS & ARCHITECTS PROPOSAL FORM In accordance with the provisions of the Insurance Contracts Act 1984 insurers are required to advise you of your responsibilities in relation
QBE PROFESSIONAL INDEMNITY CONSTRUCTION CONSULTANTS PROPOSAL FORM
QBE Insurance (International) Limited Unique Entity No. S16FC00047K 60 Anson Road #11-01 Mapletree Anson Singapore 079914 Tel: 65-6224 6633 Fax: 65-6433 3270 www.qbe.com.sg QBE PROFESSIONAL INDEMNITY CONSTRUCTION
THE POWER TO BUILD YOUR BUSINESS
THE POWER TO BUILD YOUR BUSINESS FIND out how our products and services can power your business to success the power behind your business who we are NICEIC and ELECSA are leading voluntary regulatory bodies
A&E A&E. ProSurance TM. Application Form INSURANCE FOR ARCHITECTS & ENGINEERS
A&E INSURANCE FOR ARCHITECTS & ENGINEERS ProSurance TM A&E Application Form This is an application for an errors and omissions package policy designed specifically for architects and engineers. As well
Building and Engineering Contractors Proposal Form
Building and Engineering Contractors Proposal Form This Proposal form must be completed in ink, signed and dated by a Principal, Partner or Director of the Proposer. All questions must be answered and
QBE Professional Indemnity Proposal Form Construction Consultants
Notice to the Proposed Insured QBE Professional Indemnity Proposal Form Your duty of disclosure If a proposer does not fully and faithfully give the facts as he knows them or ought to know them, he may
Schedule - Tradesman Insurance Essentials
Schedule - Tradesman Insurance Essentials The Insured The Insured's Business Mr Arthur Dube Arthur Contracting Services Cleaning - general services Landscaping and drainage The Insured's Postal Address
Contractors Combined Insurance
Contractors Combined Insurance SCHEDULE TO THE POLICY Policy Number B1053BAGL027 XLTS0258 Insurance Broker Camberford Law Plc Lygon House 50 London Road Bromley, Kent BR1 3RA Assured: TreeAbility Ltd Of:
CONFIRMATION OF ORDER
CONFIRMATION OF ORDER Employers, Public and Products Liability Quote Sheet Reference Number: 7B5310GLA153 Underwriter: Steve Palmer Date: 09/02/2015 Broker: R.K.Henshall & Co.Limited Broker Contact: Laura
PROPOSAL FORM. Bajaj Allianz General Insurance Company Limited WORKMEN'S COMPENSATION INSURANCE P - 2801 -
Bajaj Allianz General Insurance Company Limited P - 2801 - PROPOSAL FORM WORKMEN'S COMPENSATION INSURANCE THE INDIAN WORKMEN'S COMPENSATION ACT 1923. The Act provides for the payment of compensation by
Insurer Thistle Underwriting acting in an underwriting capacity on behalf of those Lloyd s Underwriters subscribing to the above policy.
CONTRACTORS & ENGINEERS POLICY Please read this document carefully This is a summary of the cover provided by your Policy. It contains references to the key features and benefits of the Policy as well
COMMERCIAL INSURANCE PROPOSAL FORM COVER DESIGNED FOR YOUR BUSINESS
COMMERCIAL INSURANCE PROPOSAL FORM COVER DESIGNED FOR YOUR BUSINESS This Proposal is for use by special agreement with NIG in connection with their range of Commercial Non-motor Policies other than Motor
COMBINED GENERAL LIABILITY POLICY PROPOSAL FORM
COMBINED GENERAL LIABILITY POLICY PROPOSAL FORM Intermediary: This is your proposal for insurance. It will be the basis of any subsequent insurance policy that the Company may issue to you. You are obliged
Semploy Extra Statement of Fact and Schedule
POLICY NUMBER: 9051938L Page 1 of 7 Semploy Extra Statement of Fact and Schedule Effective Date: 27 May 2015 00:00 Expires On: 26 May 2016 24:00 Agent Number 23303W Date of Issue 27 May 2015 Agency Reference
Proposal Form. Construction Industry Consultants Professional Indemnity
Proposal Form Construction Industry Consultants Professional Indemnity Important Notices Please read these notices before completing the Proposal Form. Your Duty of Disclosure Before you enter into a contract
CERTIFICATE OF EMPLOYERS LIABILITY INSURANCE
ACE European Group Ltd. UK Head Office: The ACE Building 100 Leadenhall Street London EC3A 3BP 020 7173 7000 tel 020 7173 7800 fax www.aceeurope.co.uk CERTIFICATE OF EMPLOYERS LIABILITY INSURANCE (Where
CONSULTING GEOLOGIST PROFESSIONAL INDEMNITY PROPOSAL FORM
Thompson Insurances Corporate and Personal Brokers 16, Upper Grand Canal Street, Dublin 4, Ireland. Tel: + 353 1 481 7700 Fax: + 353 1 6604058 Email [email protected] Web Site www.nti.ie CONSULTING GEOLOGIST
Architects and Engineers Professional Liability Proposal Form
Notice:Statement pursuant to Section 25(5) of the Insurance Act (Cap 142) or any amendments thereof; You are to disclose in this application, fully and faithfully, all the facts which you know or ought
Builders Property owners Golf clubs Theme parks Attractions Amusement arcades Textiles Warehouses Precision engineering Mechanics Building
Builders Property owners Golf clubs Theme parks Attractions Amusement arcades Textiles Warehouses Precision engineering Mechanics Building Contractors All Risks Insurance Construction Cleaning contractors
ZURICH TRADESMAN SCHEDULE
ZURICH TRADESMAN SCHEDULE Policy Number ZT0002903 Date 20/03/2014 The Insured Mr Matthew Watson T/A Signal Solutions The Agent Grayside Ltd Agency Number 35021 Agents Reference WAMX11TM02 The Business
Commercial General Liability Insurance Proposal Form
IMPORTANT NOTE Commercial General Liability Insurance Proposal Form Certain Underwriters at Lloyd s and/or Companies (Insurers) acting through their agent International Underwriting Agencies Ltd ( IUA
PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM ARCHITECTS AND CONSULTING ENGINEERS ANNUAL COVER
PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM ARCHITECTS AND CONSULTING ENGINEERS ANNUAL COVER I. General data Name of firm. Address of head office. Address of branch office(s) and name(s) of resident
