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 firm who has been duly authorised by all partners, principals or directors for this purpose. It is your duty to disclose all material facts to Underwriters. A material fact is one that is likely to influence underwriter s judgement and acceptance of your proposal. You must answer all questions correctly and provide all material information. Failure to do so may prejudice you under the policy or the premium that you are requested to pay. If there is insufficient space to answer questions, please use an additional sheet of paper and attach to this form. 1. i) Name of Proposer and Trading Title 2. Address (from which this business is undertaken) Postcode Tel no YEAR ESTABLISHED ERN CODE EL ONLY (REQUIRED AS A RESULT OF LEGISLATIVE CHANGES / ELTO REQUIREMENTS) (Employer Reference Number) IS THIS THE PARENT OR CHILD COMPANY (I.E. SUBSIDIARY OR TRADING NAME) COMPANY REGISTRATION NUMBER 3. Trade or business carried out (full description) 1
i) Please supply details of any separate businesses in which you or your directors are, or have been involved with in the last 5 years: Name of Business Trade To From ii) Have you or your directors or partners ever been charged with a criminal offence other than motoring offences? If YES, please provide details 4. Full description of activities 5. Please indicate covers required: (A) Employers Liability (B) Public Liability (C) Products Liability In respect of (B) and (C) please select Limit of Indemnity required: i) 1,000,000 ii) 2,000,000 iii) 5.000.000 Please state the estimated annual payments for the next 12 months for: i) Clerical/ administrative ii) Directors non manual iii) Directors manual iv) Other non manual/supervisory v) Manual at own premises only (direct employees) vi) Manual at own premises only (labour only sub- contractors) vii) Manual work away and at height (direct employees) viii) Manual work away and at height (labour only sub -contractors) ix) Manual work away at ground level only (direct employees) x) Manual work away at ground level only (labour only sub -contractors) xi) Drivers (direct employees) xii) Drivers (labour only sub -contractors) xiii) Bona-Fide Subcontractors Please state the estimated turnover (i.e. gross income) of the business during the next 12 months: i) Contracting ii) Sales only iii) Hire only TOTAL 2
In respect of Roofing activities only, Please state the estimated turnover in respect of: a) Slating and tiling b) Mastic asphalt, flat and felt roofing contracts c) Industrial sheeting and cladding contracts d) All other roofing contracting e) All other contracting turnover f) All non contracting turnover Please advise the nature of any turnover advised for items d), e) and f) above 6. Do you conduct any business outside of Great Britain, the Channel Islands or the Isle of Man? If YES, please provide details 7. Do you vet the insurance arrangement of sub-contractors and retain a copy of written evidence of such insurances? If YES, describe criteria for approval If NO, please state reasons or confirm future intention to do so Your working practices/ environment 8. Do you, or do your sub contractors, use blow lamps, blow torches, hot air guns, tar, bitumen or asphalt heaters, electric oxy-acetylene or other burning, welding or flame cutting equipment, or any process involving the application of heat away from your premises If YES, please provide full details of wages and percentage of turnover: a) Blow lamps, blow torches, hot air guns % b) Tar, bitumen or asphalt heaters % c) Electric oxy-acetylene or other burning, welding or flame cutting equipment % Is all hot work undertaken at ground level? If NO, please provide details: 9. Are any of the following used (or have been used in the past) in your business? a) Asbestos, silica, or other substances involving a possible lung hazard or any acids, gases, chemicals or explosives or any materials containing such substances, including asbestos roof sheeting? b) Radioisotopes, radioactive substances or other sources of ionising radiations c) toxic or hazardous component building materials 3
d) Power driven machinery (other than hand tools) If "Yes" to any question (a) to (d), please give details: e) Lifts, hoists, cranes, abseiling equipment and the like (other than designed for the raising, lowering or transportation of inanimate materials) If "Yes" to (e), with which engineering office has an inspection contract been arranged? 10. Does your business result in any impairment of the environment, e.g. chemical effluents, fumes? 11. Are employees now, or have they ever been, exposed to noise at such levels that their hearing may be impaired? If YES, please detail action taken to prevent hearing impairment 12. Is any advice, plan, design formula or specification given in connection with any product supplied (other than normal instructions for proper use or maintenance)? 13. Applicable to Scaffolding Contractors Only: Do you provide a Handover Certificate on each occasion that scaffolding is handed over to a customer? IF NO, please state reasons or confirm future intention to do so: 14. Maximum height worked to: a) up to 10 metres % b) up to 15 metres % c) up to 20 metres % d) over 20 metres % 15. Do you conduct any depth/ excavation work? If YES, please provide details including maximum depths worked to: Management of Employee Safety 16. Do you have: a) a formal written Health and Safety Policy? b) a formal safety training plan for employees? c) a documented procedure for high risk activities? d) a formal documented accident investigation plan? e) By what process do you minimise the likelihood of reoccurrence following an accident at work? 4
f) Do you always retain Health and Safety assessment records? Instruction and training records? Method statements / work instructions? RIDDOR forms? Contract and sub contract documentation? Copies of certificates of insurance issued to CIS5 and CIS6 card holders? g) Have you been subject to any enforcement measures, prohibition notices or criminal proceedings in the last 5 years? IF yes, please provide details: 17. Are your works, machinery and plant properly fenced and otherwise in good order and regularly inspected to comply with statutory requirements? IF No, please provide details: 18. Are you: 1. a member of the National Federation of Roofing Contractors? 2. A member of the National Association of Scaffolding Contractors? 3. a member of the Construction Industry Training Board? 4. a member of another trade association? Please specify In respect of scaffolders only: 5. Do in excess of 75% of your operatives hold CSCS Cards? 6. Are in excess of 75% of your operatives qualified? Types of premises worked upon 19. What percentage of your turnover is work carried out at the following locations: - New build properties only? % - Private dwelling houses and flats? % - Commercial buildings? % - Industrial buildings? % - Local authority amenity buildings? % - Other? % Please supply details: 5
- Do you undertake any propping or shoring work If Yes, please provide details of the largest three contracts completed during the past 24 months: High Risk Locations 20. Do you work on or in connection with any of the following areas: - Spectator stands - Demolition sites - Ministry of defence properties - Nuclear sites - Refineries - Airports - Towers, steeples or spires If YES, please detail any work conducted at heights above 20 metres above ground level or floor level in the case of work inside or upon a building or structure? - Viaducts or bridges - Docks, Piers or wharves - Offshore - Power stations - Quarries - Pylons - Tunnels, wells or mines - Radioactive substances / devices - Explosives - Blast furnaces - Vehicles, vessels, ships, boats, hovercraft - Railways - Dams (including coffer dams), bridges or underwater workings? 6
If yes to any of the above, please provide full details: Your Policy Excess 21. Please indicate if you wish to carry an increased excess in respect of third party property damage: Increased Excess Yes 2,500 5,000 10,000 15,000 20,000 Other, please detail: Insurance History 22. Name of previous insurers 23. Date of expiry of previous policy 24. Has any insurer cancelled, refused to continue or agreed to continue only on special terms, any insurance for the Proposer or any other person to whom the insurance would apply? If "Yes" state the reasons: 25. Claims Declaration Please confirm that you have approved any authenticated claims experience supplied by your broker which form part of this proposal Claims Experience 5 years:(if none state NONE) Employers Liability Public/Products Liability Date of incident Settled o/s Settled o/s 7
DATA PROTECTION The defined terms used in this section shall have the meaning given to those terms in the Data Protection Act 1998 (as may be amended from time to time). In the course of providing insurance services to the proposed insured/insured, the insurer may have access to Personal Data. The proposed insured/insured warrants that it shall have obtained all necessary authorisations and approvals from Data Subjects prior to disclosing any Personal Data to the insurer (whether such disclosure is made directly by the proposed insured/insured to the insurer or indirectly by the proposed insured/insured to any agent acting on behalf of the proposed insured/insured or the insurer). The insurer shall be the Data Controller of any Personal Data provided to it. The insurer undertakes that it shall only use any Personal Data provided to it for the purposes of performing its services in connection with its contract of insurance with the proposed insured/insured. This will include the processes of underwriting, administration and claims assessment as well as any necessary services ancillary thereto. The insurer will hold all Personal Data provided to it securely and shall limit access to such Personal Data to those who have a need to see it. The proposed insured/insured hereby consents to the insurer sharing any Personal Data provided to it with its group companies, agents, reinsurers, claims handlers, loss adjusters, medical professionals and other professional advisors, healthcare management companies and any other necessary service providers with whom the insurer contracts in connection with the proposed contract/contract of insurance between the proposed insured/insured and the insurer The insurer acknowledges that the insurer may be required as a matter of law or regulation to disclose Personal Data provided to it to a Court of law or regulatory body such as the Financial Services Authority or any other public body or authority of competent jurisdiction and the proposed insured/insured hereby consents to any such disclosure. The proposed insured/insured acknowledges that the insurance industry maintains certain registers for the purposes of fraud prevention and hereby consents to the insurer sharing Personal Data provided to it with fraud prevention agencies and other insurance companies for the purposes of fraud prevention and to validate your claims history DECLARATION I/We declare that to the best of my/our knowledge and belief:- I/We agree the information provided in connection with this Proposal, whether in my/our hand or not, is true and I/We have not withheld any material facts. I/We understand that non-disclosure or misrepresentation of a material fact will entitle Insurers to void any insurance granted. (N.B. A material fact is one likely to influence acceptance or assessment of this Proposal by Insurers; if you are in doubt as to what constitutes a material fact you should consult us). I/We confirm that no work is undertaken which involves the handling and/ or stripping out of asbestos insulation, asbestos coating, asbestos insulation board and/or any other substance incorporating asbestos. I/We understand that the signing of this Proposal does not bind me/us to complete the insurance but agree that, should a contract of insurance be concluded, this proposal and statements made therein shall form the basis of such contract. Date cover required from: Signature: Position: Dated: 8