PUBLIC LIABILITY INSURANCE
MOTOR SPORTS RISK SERVICES
Public Liability Insurance
New Risk Questionnaire
Please complete, sign and return together with the attachments to:
Motor Sports Risk Services
A Division of Lockton Companies LLP
19 Spring Gardens
Manchester
M2 1FB
Tel:+44 (0)161 828 3300
Fax:+44 (0)161 828 3335
© Motor Sports Risk Services
IMPORTANT NOTICE REGARDING COMPLETION OF THIS PROPOSAL FORM
1
.
Disclosure- Any “material fact” must be disclosed to Insurers.
- A “material fact” is any information, which may alter the judgement of an Insurer in assessing a risk. - Any “material change” must be disclosed to Insurers.
- A “material change” is any information which may alter the judgement of an Insurer or their perception of risk and exposure that has not previously been disclosed as a material fact.
(If you are unsure whether a fact or change is material or not, you should disclose it.)
Failure to provide all “material facts” and/or notify all “material changes” may cause the contract of insurance to be void and may result in Insurers repudiating liability entirely.
2. Presentation
- This Proposal Form must be completed in ink by an authorised individual, a Partner/ Principal/ Member or Director of the Firm.
- All questions must be answered.
- If there is insufficient space to provide answers, additional information should be provided on the Company’s letter headed paper.
- Where available brochures, standard contract conditions, conditions, agreements and letters of appointment should be provided.
Failure to present Insurers with information in an appropriate manner may adversely influence the ability of Insurers to offer terms.
3. Guidance
- If in doubt as to the meaning of any question contained within this proposal form or the issues raised in (1) or (2) above, please contact an Account Executive at Lockton.
Additional information should be provided on separate sheets (ideally on Company Headed notepaper), clearly identifiable as forming part of the proposal form.
1. Title of Insured to be:
2. Address
Post Code:
Tel No: Fax:
E-mail: Website:
3. Full Business Description to be insured:
4. Please provide a brief CV outlining previous relevant experience; any qualifications etc:
5. Please provide details of where the insured is affiliated to/approved by/members of:
6. Is this a new venture? YES NO
© Motor Sports Risk Services
7. Have there been any incidents in the past, which could have given rise to a claim? YES NO
If ‘YES’, please provide details.
8. Will you have exclusive use of the venue at the time of your activity? YES NO
If ‘NO’, please provide details of what other use there is.
9. How will spectators (parents, friends etc) be controlled/confined?
10. Do you allow non-participating spectator attendance? YES NO
If ‘YES’, please provide the approximate numbers per event.
11. How will they be controlled/confined?
12. Will all Aviation activities be suspended during your use of the venue? YES NO If ‘NO’, please provide details.
13. How precisely will your activity be organised and supervised (to mitigate the risks involved)?
14. What age groups will participate and what restrictions will be applied?
15. What instruction, tuition, advice or maintenance is provided by the insured?
16. What first aid facilities will be provided and by whom?
17. What fire protection facilities will be provided and by whom?
© Motor Sports Risk Services
18. What vehicles and equipment will be supplied by the insured?
19. What safety devices (cut-outs, speed restrictions etc) are your vehicles equipped with?
20. What type of helmets are provided? Open face Full face
21. What additional safety equipment do you supply?
Back Protectors Gloves Overalls Full harness Belts
Other
22. Please list each of the activities/services you offer:
23. What percentage of your business involves:
Arrive and drive
Tuition/instruction
Corporate Entertainment
Under 18 years olds
Other (please specify)
24. Will the track /circuit be marshalled enabling total visibility of the whole track/circuit etc at all
times? YES NO
25. Do you have a nominated Safety Officer in attendance? YES NO
26. Are your officials in radio contact? YES NO
27. What is the minimum training/experience of your officials?
28. Who has provided your cover previously and has any insurer declined to renew the policy?
29. Do you require Employers Liability cover? YES NO
If ‘YES’, please advise number of employees and annual estimated wages for the forthcoming
year with a brief note of their duties.
30. What is the anticipated financial turnover during the next 12 months?
31. What is your anticipated number of clients/customers during the next 12 months?
32. How many customers would be in attendance on a typical day?
© Motor Sports Risk Services
34. What qualifications or experience are your customers required to have prior to participating?
35. Do you provide catering yourselves? YES NO
36. Is alcohol available to anyone attending your activity? YES NO
If ‘YES’, please provide details.
37. Please advise names of any other insurers/brokers who are providing you with quotations for this risk so that we do not
duplicate an approach to them:
38. Please enclose the following
1. Specimen copies of your advertising material /booking forms etc 2. A copy of your risk assessment you have carried out
3. A simple plan showing your venue, the track and any public rights of way traversing the area of your activity or immediately adjacent to it
4. Copy rules/regulations applying to your activity
5. A note of your minimum requirements for a suitable venue (maybe a copy that would be issued to a prospective venue operator/landowner)
DATA PROTECTION
By signing this proposal form you consent to Lockton using the information we may hold about you for the purpose of providing insurance and handling claims, if any, and to process sensitive personal data about you where this is necessary (for example criminal convictions). This may mean we have to give some details to third parties involved in providing insurance cover. These may include insurance carriers, third-party claims adjusters, fraud detection and prevention services, reinsurance companies and insurance regulatory authorities. In the course of performing our obligation to you, this information may be disclosed to agents and service providers appointed by us, insurers, (which includes their re-insurers, legal advisers, loss adjustors or agents). Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use by us as set out above. The information provided will be treated in confidence and, where appropriate, in compliance with the relevant Data Protection legislation. You have the right to apply for a copy of your information (for which we may charge a small fee) and to have any inaccuracies corrected.
DECLARATION
I/We declare that the above statements and particulars are true, full enquiry having been made, and I/We have not omitted, suppressed or mis-stated any material facts which may be relevant to Insurers' consideration of this proposal form and undertake to inform the Insurer of any change to any material fact that occurs prior to the point at which the insurance contract has been agreed.
I/We understand that the information I/We provide will be used in deciding the price charged by the Insurer for the risk and whether the Insurer will accept the application and the terms of any policy provided.
PRINT NAME:
SIGNATURE:
ON BEHALF OF:
DATE:
If completing online, please save your form and visit the Contact Us section for details on where to send your completed form. Please note, if you wish to submit your form via email, an indication of terms and conditions may be provided on the basis of this proposal form. An original
signature is required before a contract of insurance can be made. Encrypted signatures are not acceptable.
Signing this form does not bind the Company to complete the insurance
We recommend that you keep a record of all information supplied to us, including copies of letters and this proposal form, for the purpose of entering into this contract.
From time to time, we may disclose personal information (other than sensitive personal data) to other Lockton Companies. We or they may use that information to advise you of our services which may be of interest to you. If you would prefer not to receive information, please contact an Account Executive at Lockton.
Motor Sports Risk Services A Division of Lockton Companies LLP.
Registered in England & Wales at The St Botolph Building, 138 Houndsditch, London EC3A 7AG Company No. 1211673
Lockton House, 6 Bevis Marks London EC3A 7AF
Our Mission
To be the worldwide value and service leader in insurance brokerage and risk management services
