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PROPOSAL FORM
GENERAL BUSINESS
LIABILITY INSURANCE
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.
Please read the following information carefully as this forms an important part of any Insurance bound.
MATERIAL FACTS
A Material Fact a fact which may influence a (re)Insurer’s judgement in their assessment of a risk, including its terms and pricing. Therefore it is your duty to disclose all material facts as this may affect the validity of these terms and any Insurance bound subsequently. If you are in any doubt as to whether a fact is material we recommend that it be disclosed.
You should also keep us advised of any changes to Material Facts as these may also need to be disclosed. Failure to disclose Material Facts may entitle (re)insurers to avoid the policy from inception. Examples of Material Facts are:
1. Circumstances which might give rise to a Claim or 2. Information on the nature of the work undertaken or 3. Change to the location of work (i.e. territories overseas not previously advised)
You should keep a record of all information supplied to the Insurer.
Answers such as “See Presentation” or “See your records” should not be used.
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 are requested to pay.
If there is insufficient space to answer questions, please use an additional sheet and attach to this form.
Name(s) of Company / Sole Trader to be insured including any Subsidiary Company(s) to be included in this Insurance:
……….………..…… Address (including Postcode): ……….. ……… Telephone Number: ………..………..…… Fax Number: ………
Website: ………..……… Email address: ………
Business Description: ………..……….………..……
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……… Describe Processes and Activities: ………..……
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Should you require Employers Liability, the following information MUST be provided: Employer Reference Number (ERN) also Full Name & Address of any subsidiary
referred to as Employee PAYE Reference for Companies: both the Insured and their Subsidiaries:
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Date Established: ………..
If new, give details of experience: ………..
……… Confirm local Authority and H.S.E Registration: YES / NO Have you entered into any contract which imposes upon you
liability for which you would not otherwise be liable? YES / NO
Do you own premises or have any representation outside the United Kingdom? YES / NO If YES please provide full details: ………..
……… Is this operation(s) the subject of local Insurance arrangements? YES / NO If YES please provide full details:
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Are all employees United Kingdom nationals? YES / NO If NO state number and Nationality of foreign employees: ………..
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Do you use Sub-Contractors? YES / NO
If YES do you check they hold their own Insurance and are therefore not to be covered under your Policy? YES / NO
Have you or any of your Directors or Partners ever been charged with a
Criminal offence other than a motoring offence? YES / NO Has any Insurer ever declined to insure you or refused to renew any of your insurances? YES /NO
If you answered YES to any of the above, please provide full details (including identity of Insurers):
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Please provide details of present Liability Insurer(s), expiry date(s) and policy number(s):
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If cover is required outside the UK mainland, please state in which Countries and locations (i.e. Republic of Ireland/Northern Ireland, West Africa and/or North America) and Summarise activities undertaken:
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Do you require:
Yes No Indemnity Limit Required
Employers Liability GBP
Public/Products Liability GBP
Date from which cover is to commence: ________________________________
RISK PROFILE – EMPLOYERS AND PUBLIC/PRODUCTS LIABILITY
EMPLOYERS LIABILITY
Summarise estimated annual payments to all Employees and including Labour Only Sub Contractors.(Payments means wages, including overtime, standby time, bonuses, National Insurance and Pension contributions and Income Tax).
Category Estimated number
of Employees
Location Estimated Annual payments to all
Employees
Actual Annual Payments for last
12 months Clerical/Managerial
Manual - Premises
Manual Work Away excluding Heat Manual Work Away including Heat Offshore
Payments to Bona- Fide Subcontractors All Other Employees
(please specify functions)
Give details of any separate business in which you or your Directors or Partners are or have been involved during the last 5 years.
Name of Business Trade From To
____________________________________ _____________________________ _____________ _____________ ____________________________________ _____________________________ _____________ _____________ ____________________________________ _____________________________ _____________ _____________
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PUBLIC/PRODUCTS LIABILITY
Turnover Actual/Previous 12 Months Estimated Next 12 Months
United Kingdom
USA/Canada
Any other Turnover (please specify)
PREMISES – Please provide full details
Address Purpose Owned/ Sole /
Leased Multi Occupation a) ______________________________________ ________________________ _______________ _______________
b) ______________________________________ ________________________ _______________ _______________
c) ______________________________________ ________________________ _______________ _______________
ACTIVITIES - Do your activities include any of the following?
a) berthing facilities for ships/watercraft YES / NO b) landing facilities for aircraft/hovercraft YES / NO c) railway sidings, terminals or crossings YES / NO d) fork-lift trucks, bobcats, JCB’s or other rider operated plant YES / NO e) toxic or harmful substances likely to produce significant pollution if not
contained on site or correctly discharged YES / NO
Please enter full details here (including numbers and type of fork-lift trucks and other rider operated plant):
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WORK AWAY
If you undertake work away from your premises other than collection and delivery, sales, promotional trips and exhibitions:
a) What is the nature of such work?
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……… b) Is work in excess of 15 metres high? YES / NO c) Is it on or within aircraft, airports, ships, docks, mines, chemical, gas or oil processing
plants or storage/container installations or nuclear installations? YES / NO d) Is it on or within offshore installations? YES / NO
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e) If you use heat away what type of cutting/grinding/burning equipment is used?
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……… f) Do you have a ‘safe working with heat equipment’ procedure? YES / NO Please provide full details here:
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PLEASE PROVIDE FULL DETAILS IN RELATION TO THE FOLLOWING HEALTH AND SAFETY QUESTIONS Your answers to the questions under ‘Section 18: Health and Safety at Work and Welfare’ will be taken into
consideration as part of the investigation process in the event that you make a Claim under the policy. When dealing with Claims, we will consider whether poor Health and Safety controls may have contributed to the
incident and this may be reflected in the renewal premium.
HEALTH AND SAFETY AT WORK AND WELFARE GENERAL
a) Do you have a Health and Safety policy which is available to your
staff and visitors? (if yes, please append a copy to this submission) YES / NO
b) By what processes to you ensure that your Health and Safety policy is kept up to date?
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c) By what process do you minimise the likelihood of recurrence following an accident at work?
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d) How do you benchmark your Health and Safety processes and performance either internally or externally?
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……… e) Please confirm that you always retain the following documentation:
Health and Safety risk assessment records YES / NO Instruction and training records YES / NO Method Statements / work instructions YES / NO RIDDOR Forms YES / NO Contract and Sub-Contract documentation YES / NO Copies of certificates of Insurance issued to CIS5 and CIS6 holders YES / NO
f) Please advise any dealings that your Company has had in the last 5 years with the Health and Safety Executive, an Environmental Health Officer or any other enforcement agency and if you have been the subject of enforcement measures, prohibition notices or criminal proceedings:
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RISK ASSESSMENT
g) How do you assess and minimise the risk to Health and Safety arising from the following;
a) (i) The provision and use of work equipment: ………
……… (ii) Fork-lift Trucks or other rider operated plant
(1) Are all of your Fork-lift Truck or other rider operated plant drivers at least 18 years of age and trained in accordance with the HSE Code of Practice 26 or any
replacement regulations? YES / NO
(2) Have all Fork-lift Truck operatives completed a training course In the safe use of Fork-lift Trucks through an Accredited Training Provider belonging to
one of the 5 accredited bodies as recognised By the HSE? YES / NO
(3) Do the operatives complete a refresher course within 5 years of the initial training programme? YES / NO b) Manual Handing: ………..………
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c) Noise in the workplace (Processes in excess of 85dB (A)): ………
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d) Substances hazardous to health: ………
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e) Hand/arm vibration ……….………
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f) Repetitive strains ………
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g) Stress ………
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h) Working at heights ………
……… h) In relation to any construction or building operations, what steps are taken to ensure compliance with Construction (Health, Safety and Welfare) Regulations? ………..………..………
……… i) What steps are taken to ensure compliance with Workplace (Health, Safety and Welfare) Regulations?
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……… j) Have you documented your strategy for compliance as a Duty Holder under the Control of Asbestos at Work
Regulations 2002 and prioritised action?
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……… MANAGING SAFETY
k) Please describe the company training and instruction policy with reference to certification, induction training and toolbox talks:
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l) Please describe the Company policy on Personal Protective Equipment with special reference to enforcement:
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m) Please provide any other information, regarding Health and Safety at Work or otherwise, which you believe to be relevant to Insurers’ consideration of this risk.
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……… WELFARE
n) In the event that an Employee is injured at work, do you, as a matter of policy;
(i) Provide rehabilitation/medical care to facilitate the return to work? YES / NO (ii) Continue to pay the Employee’s wages following the accident? YES / NO If so, on what basis?
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(iii) Make efforts to re-deploy Employees on alternative tasks/jobs during recovery period? YES / NO (iv) Pursue other forms of initiatives to accelerate well being and return to fitness? YES / NO
PRODUCTS PROFILE –
PRODUCT LIABILITY AND QUALITY MANAGEMENT
a) Please provide a detailed description of products supplied, and, if appropriate, terms of hiring out agreements:
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……… b) Please provide details of products exported to the USA or Canada within the last 3 years:
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……… c) Please provide full details of any product used
i) in aircraft: ii) in marine craft: iii) offshore:
d) Please provide full details of imported products including source of origin and amount:
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……… e) If you provide any services or treatment other than products please provide details:
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……… f) Do you retain Rights of Recourse against manufacturers/suppliers? YES / NO g) Do any of your products require an accompanying hazard warning? YES / NO h) Do you design or prepare specifications for the products you supply? YES / NO If YES, please provide full details (including qualifications of design team):
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……… i) Please provide details of your quality control systems and procedures (e.g. ISO 9000) including any ‘early warning’ mechanism built into your complaints procedure:
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……… j) Please provide details of any product line know to be harmful to health:
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……… k) Please indicate period of time, in years, that you retain stock records of:
Customers ………. Suppliers ……….
Please provide full details of work undertaken including involvement with any trade acknowledged hazardous substances:
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Have you any history of prolonged absence of employees due to stress? YES / NO If YES, please provide full details:
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Are you aware of any recorded instances/Claims for GDD (Gradually Developing Diseases) such as Deafness, Repetitive Strain Injury, Vibration White Finger, Chest/Lung Condition/ Cancer,
Asbestosis (or similar conditions) made against you or about to be made against you? YES / NO
If Yes, please provide the following information:
Year Type of GDD No. of Claim Amount of Claim Insurer
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CLAIMS EXPERIENCE
Please confirm that you have approved the authenticated Claims Experience
supplied by your Broker which forms part of this Proposal YES / NO
CLAIMS HISTORY RECORD
Details of all Claims made against the Proposer during the past five years.
FOR EMPLOYERS LIABILITY
State number and details of accidents to your Employees during the past five years in respect of Claims made against you (please use a separate sheet if necessary)
SETTLED CLAIMS RESERVES FOR OUTSTANDING
CLAIMS
YEAR HISTORIAL
MANUAL WAGES
NUMBER COST NUMBER COST
Please provide separate details in the space below of claims and/or any other incident in the last five years not included in (a) above reported under RIDDOR. (please use a separate sheet if necessary)
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……… FOR PUBLIC/PRODUCTS LIABILITY
State number and details of all Public/Products Liability claims made against you during the past five years.
SETTLED CLAIMS RESERVES FOR OUTSTANDING
CLAIMS
YEAR HISTORIAL
TURNOVER
NUMBER COST NUMBER COST
In respect of Public Liability, please supply details of any other allegations made against you by any Third Party but where no formal Claim has been made by them &/or advised to your Insurers by you (please use a separate sheet if necessary):
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Please provide below (or attach a separate sheet to this form) any additional information that you wish to bring to the attention of the Insurer(s):
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DECLARATION
NOTICE AND WARNING ABOUT MATERIAL FACTS ON PROPOSAL FORM.
Please be reminded that failure to disclose all material information, i.e. Information which is likely to influence the acceptance of the risk and the terms applied, could invalidate the Insurance. If you are in any doubt as to whether any information is material, it should be disclosed.
I declare that the statements and particulars in this Proposal Form are true and no Material Facts have been
suppressed. I / we understand that this Proposal, together with any other information supplied, shall form the basis of any contract of Insurance hereafter. I / we confirm that no work is intentionally 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 undertake to inform Insurer’s of any material alteration to these facts occurring before the completion of the contract of Insurance.
I /we hereby authorise the Insurers to approach any of my/our previous Insurers to confirm the accuracy of any information given in this Proposal.
Signed _________________________________________ on behalf of the Proposer
Print Name _________________________________________
Position _________________________________________ Date _________________________
