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Fields marked *
are required
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| Max number of persons employed at any
time : |
Clerical work only :
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Manual work only :
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| Trade or business and full description
of all business activities : |
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Give details of any products you Manufacture, Sell,Process, Repair,
Alter, Test, Treat, Supply, Install, Erect or Fit : |
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| Date cover to commence : |
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| Please answer all of the following questions
carefully. In order to avoid delay it is important no blank spaces
are left. |
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1. Please
check the limit of indemnity required
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Public and Products liability
:
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| Employers Liability : Automatic 10M |
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| 2.
How long have you been trading: |
Years
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| 3.
Are you at present insured or have you ever been insured in respect
of the classes of insurance now proposed? |
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| If 'Yes' please state name
of insurer: |
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| 4.
Has any insurer ever declined your proposal, cancelled or declined
to renew your policy or required increased premium or imposed special
terms? : |
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| If 'Yes' please provide full
details: |
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| 5.
Have you or any director or partner ever been |
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| i)
Convicted of or charged (but not yet tried) with any criminal offence? |
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| ii)
Declared bankrupt or insolvent? |
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| iii)
Prosecuted under the Health and Safety at Work Act or any other
statute or regulation? |
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| If you have answered 'Yes'
to any of the above please provide full details |
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| 6.
Please provide full particulars of any of the following used by
your business |
| I)
Woodworking machinery |
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ii) Other power-driven machinery |
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| iii)
Lifts, cranes, hoists, fork lift trucks, diggers, bulldozers or
the like |
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| 7.
Do any of your employees work on or visit: |
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| I)
Offshore installations? |
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| ii)
Ships, other water-borne vessels and/or aircraft? |
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| If 'Yes' please provide full
details including number of persons below |
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Number of persons:
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| 8.
Do any of your employees work overseas? If so please provide full
details including number of persons |
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Number of persons:
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| 9.
Please state maximum height worked at by any employees (Metres) |
metres
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| 10. Please
state maximum depth worked at by any manual employees (Metres) |
metres
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| 11.
Are any of your employees exposed to noise levels above 85db? If
'Yes' what provisions are made to protect employees? |
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| 12.
Have any of your employees complained of injury, including repetitive
strain injury, pain in their upper limbs, numbness, discoloration
or back pain? |
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| If 'Yes' please provide full
details (including any preventative measures taken) |
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| 13.
Are any of your employees exposed to:- |
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| i)
asbestos, silica acids, gases, chemicals, explosives or other hazardous
toxic waste substances including isocyanates and dioxins |
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| ii)
other substances or chemicals which are known to be associated with
skin disorders cancer or respiratory conditions |
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| iii)
radio isotopes, radioactive substances or other sources of ionising
radiation |
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| If 'Yes' please provide full
details (including any preventative measures taken) |
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| 14.
Have you completed all assessments as required under COSHH regulations? |
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| If 'No' please give full
details of your proposed program of implementation |
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| 15.
Please state the maximum number of employees at any one location
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employees
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| 16.
Do you or have you in the past discharged either intentionally or
unintentionally trade waste chemicals effluent fumes or anything
of a noxious nature into water (including sewers and drains) land
or the atmosphere? |
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| If 'Yes' please give full
details |
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| 17.
Are you aware of any risks to any third party persons or property
arising out of pollution or contamination which may occur on or
from your premises or any site worked at? |
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| If 'Yes' please give full
details |
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| 18.
Do you engage any Bona-Fide sub contractors |
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| 19.
Do you check to ensure that all Bona-Fide Sub-Contractors have their
own public liability insurance with an adequate limit of indemnity
and an indemnity to principal clause? |
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| If 'No' when do you intend
to implement such a procedure? |
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| 20.
State percentage of your turnover relating to activities of Bona-Fide
Sub-Contractors |
%
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| 21.
Do you carry our any work involving the use of heat away from the
premises? |
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| If 'Yes' please provide full
details including the percentage of your time involved |
% of time involved
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| 22.
State estimated annual turnover divided between: |
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| 23.
Have you exported either directly or indirectly any products to
the USA or Canada in the last 5 years or do you anticipate making
such exports ? |
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| If 'Yes' please provide details
of products supplied and annual turnover below. |
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| 24.
Do you retain all rights of recovery against suppliers/manufacturers/bona-fide
subcontractors? |
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| If 'No' please provide details
when you have relieved them of their responsibilities |
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| 25.
Do all products manufactured/supplied/installed by you comply with
all relevant British standards or European CE standards? |
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| If 'No' please provide full
details below |
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| 26.
Experience during past FIVE YEARS. Give dates of loss and full details
including paid and outstanding amounts below |
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DECLARATION
I/We hereby declare that the above statements and particulars which
I/We have read over and checked are true and that no information
has been withheld which might increase the risk or Influence acceptance
by the Underwriters and that should the above particulars alter
in any way I/We will advise the Underwriters immediately. I/We have
not suppressed, mis-represented or mis-stated any material fact,
have fairly estimated our Turnover and agree that this proposal
shall hold promissory and form the basis of the contract between
me/us and the Underwriters. I/We understand that failure to disclose
any material facts which would be likely to influence the acceptance
and assessment of this proposal may result in the Insurers refusing
to provide indemnity or voiding the policy in every respect.
I/We undersigned agree to render, at each period of insurance, declarations
in the form required by the Underwriters and pay any additional
premium due in excess of the amount estimated.
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