PAUL JONES INSURANCE CRICKET SCHEME
PROPOSAL FORM
This proposal form must be completed in ink by a Committee member or Director of the Club. If there
is insufficient space, please supply the information on a separate sheet of paper indicating the question
to which the answer refers.
PLEASE RETURN TO:
PAUL JONES INSURANCE, KINGS HOUSE, 316 SHIRLEY ROAD, SOUTHAMPTON, S015 3HL.
Telephone: 023 8078 8444
Fax: 023 8070 2536
E-mail: [email protected]
GENERAL INFORMATION
Club Name
Club Ground Address
Post Code:
If no post code allocated, please use nearest building to the ground.
Contact details of Club official with whom we should correspond:
Name
Postal Address
Post Code:
Email Address
1.
When was the club established?
Tel. No.
2.
Has the Club or any Committee Member held any insurances (to which this Application form relates)
which have subsequently been
a)
3.
Declined
b) Terminated
c) Refused renewal
d) Subject to special terms
Has any Committee Member or Director of the Club had any convictions, criminal offences or prosecutions
pending other than motor offences?
4.
Current insurer:
5.
Current approximate premium:
YES/NO
YES/NO
LEGAL LIABILITIES INSURANCE - Compulsory Section
Complete General Questions 1 – 12 below
The covers provided by this section are:
Public and Products Liability
Limit of Indemnity £ 5,000,000
Employers Liability
Limit of Indemnity £10,000,000
Legal Expenses
Limit of Indemnity £
100,000
GENERAL QUESTIONS
1.
Number of Adult Club members
2.
Number of junior members under 16
3.
Number of Senior teams
4.
Number of Junior teams
5.
Are any sporting activities other than Cricket to be included for Liability Insurance? If so state which?
YES/NO
6.
Do you undertake any hazardous activities e.g. Bonfire Nights, Clay pigeon Shooting,
Fetes involving Motorised equipment, bouncy castles etc. If so please supply details.
YES/NO
7.
Are your premises let out to non-members for Private functions
If so do You request proof of Public Liability Insurance
YES/NO
YES/NO
8.
Do You have a written Health & Safety Policy that is recorded, signed, dated and communicated to
new and existing employees?
(This is a compulsory requirement by law if there are 5 or more employees including part time/casual)
YES/NO
Do you have an appointed officer for the implementation of Health and Safety issues in the club?
YES/NO
9.
10. Do you have an accident book to record all incidents?
YES/NO
11. If your monthly wage bill exceeds £503 per month, please advise your Employer Reference Number
(PAYE tax reference no) or are you exempt?
YES/NO
12. Are any staff redundancies or restructures planned?
YES/NO
PROPERTY DAMAGE - BUILDINGS, CONTENTS & MACHINERY STORE- Please answer all questions.
Pavillion and Clubhouse
1.
Are your premises built of Standard Construction
(The external walls are built solely of brick, stone, concrete or dwarf brick with metal cladding on a steel frame?) YES/NO
If no or if they contain composite panels or combustible linings please provide details
2.
Are your premises roofed with slate, tile, corrugated asbestos or profile metal cladding with non combustible
linings?
YES/NO
If no please supply details.
February 2014
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3.
If you have a flat felt roof, does it exceed 10% of the total roof area ?
YES/NO
If YES please state approximate percentage.
4.
Do you have a separate Machinery Store or other outbuildings ?
5.
If so, please provide details of Construction
6.
Are all of Your premises in a good state of repair and will they so be maintained
YES/NO
7.
Do you carry out annual inspections of felt roofs and keep a log of the condition and repairs completed
YES/NO
8.
Has the Electrical System at the premises been inspected in the last 5 years and been certified
IEE compliant (or equivalent)
YES/NO
Do You have the Certificate?
YES/NO
Do you have a No Smoking Policy and assigned external areas with receptacles which are emptied regularly
YES/NO
9.
10. Is the Clubhouse open all year round?
YES/NO
YES/NO
11. If not, please advise opening periods.
12. Are the premises inspected at least every 7 days.
YES/NO
13. Do you have a licensed bar
YES/NO
14. Do You require Subsidence cover (If yes a supplementary questionnaire will be required)
YES/NO
15. Do you require terrorism Insurance cover?
YES/NO
16. Are the premises in an area previously affected by flood?
YES/NO
17. Are the premises at risk of flooding or situated within 250 metres of a watercourse or canal, lake,
reservoir, seafront, cliff or similar?
YES/NO
18. Do you take precautions to protect pipes against freezing?
YES/NO
19. Will all combustible waste be cleared and removed from within the premises on a daily basis?
YES/NO
20. Is all combustible material and waste stored at least 5 meters away from any building in a non-combustible
container?
YES/NO
Heating.
The following methods of heating are acceptable:
a)
b)
c)
d)
Low pressure hot water apparatus,
Fixed oil fire space heaters (not tropical),
Wall mounted or fixed overhead electric or gas radiant or gas convector heaters sited well clear of combustible materials
Free standing gas or electric fires.
Are your premises heated only by the above forms of heating
YES/NO
Are your premises heated by any other form of heating
If so please provide details.
YES/NO
Security
1.
Has an Intruder Alarm been installed?
YES/NO
2.
Is the Alarm connected to a Central Monitoring Station
YES/NO
If YES, please indicate the method of signalling
e.g. Digital Communicator, Redcare, RedcareGSM, Dualcom, Dualcom plus, Dualcom GPRS.
3.
Does the system incorporate an automatic fire alarm warning to a central station
YES/NO
4.
Is CCTV installed?
YES/NO
5.
If this is recorded, please advise how long recordings kept ?
6.
Are you able to comply with the Minimum Standard of Security requirements as noted below
YES/NO
If not, these may still be acceptable - please supply details of locks or alternative security measures used on all buildings.
February 2014
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MINIMUM STANDARD OF SECURITY REQUIREMENTS
I If in relation to any claim for fire explosion riot civil commotion strikers locked out workers or persons taking part in labour
disturbances malicious persons theft or attempted theft covered by this Section if You have failed to fulfil the following condition You
will lose Your right to indemnity or payment of that claim.
Unless agreed otherwise by Us in writing within 30 days of inception of this Policy You must ensure that
1. Final exit doors are secured as follows
a. timber doors by mortise deadlocks having 5 or more levers or conforming to BS3621 with matching boxed strike plate or if the door is under
45mm by rim deadlock to BS3621
b. aluminium doors by cylinder mortise lock operating a swinging lock bolt
c. UPVC doors by key operated multi-point locking devices having 3 or more locking points
d. the first closing leaf of double leaf doors must be fitted internally with bolts top and bottom
2. All other external doors and internal doors leading to common areas or other premises are secured as follows
a) by the means set out in 1 above
b) by key operated security bolts fitted top and bottom
3. All opening windows or rooflights accessible from the ground or via roofs pipe work or other structures are secured by key operated locking
devices or screwed
permanently shut with the exception of
a) louvered windows which should be replaced with a conventional window of fixed glass.
b) windows which are already protected by security grilles, shutters or bars approved by the Insurer
4.
Marine Cargo Containers and other outbuildings
Doors to be protected by a 5 lever close shackle padlock and protected by an anti tamper box or by a Close Shackle Padlock
and locking bar to BS EN 12320 minimum security level CEN 4.
5. Any security measures stipulated or agreed by Us in writing
When the Premises are closed for Business all locks and security devices must be put into effect
SELECT THE ADDITIONAL SECTIONS OF COVER YOU REQUIRE:
PROPERTY DAMAGE SECTION
BUILDINGS AND CONTENTS OF BUILDINGS
Please specify the Sums Insured required. You must ensure that these are adequate to reinstate the Property Insured and any level of
underinsurance could result in any claim settlement being significantly reduced or the claim repudiated.
SUM INSURED
Based upon rebuilding
costs, including architects
fees removal of debris,
etc
BUILDINGS
Accidental damage, Fire, lightning, Explosion, Aircraft, Earthquake, Riot Civil Commotion, Malicious
damage, Storm, Tempest and Falling trees, Flood, Escape of Water, Impact. Theft by forcible violent entry
or exit i.e. from locked building
£100 policy excess applies to all claims other than Fire, lightning, explosion and aircraft claims which is £nil
Pavilion / Clubhouse
£
Outbuildings e.g. Cricket Score Box & Machinery store
£
Other e.g. Metal containers, Flood lights
£
CONTENTS OF CLUBHOUSE
SUM INSURED
Based upon replacement
Value
Insured perils as per the Buildings section and the same Policy excess applies with the exception of frozen
foods (see below).
General Contents including machinery, plant, fixtures & fittings, furniture, stock in trade and tenants
improvements etc.
Groundsmens’ Machinery can be included but omit from this section if cover is required for machinery &
plant whilst in the open or away from premises, If this wider cover is required enter the Sum insured under
the All Risks Machines Section.
£
£
Stock of wines, sprits, cigarettes and tobacco - do not include beers & soft drinks as they are included in
the General Contents as stock (only available if general contents are insured)
Food in freezer - automatically included within Contents up to £500. If a higher sum Insured required please
state amount.
10% or £25 policy excess applies where freezer is over 10 years old
£
BUSINESS INTERRUPTION SECTION
Loss of Annual Revenue and/or additional costs following a loss under Property Damage Section
IS COVER REQUIRED?
Please state the Club’s annual income/revenue
£
£25,000 Sum Insured
YES/NO
£50,000 Sum Insured
YES/NO
February 2014
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£
Any alternative sum insured required ?
Months
The standard Indemnity Period is 12 months, please state if a longer period is required
N.B. Your Indemnity Period must be long enough to cover the period that the Club could be affected by a
serious loss and your loss of revenue sum insured must be adequate to cover your loss of revenue for
the period of the Indemnity Period.
MONEY INSURANCE
IS COVER REQUIRED?
Money in Transit, Money in premises during business hours, Money in premises out of business hours,
Money in safe, Money at homes of Club Officials
YES/NO
Money in Gaming Machines - £250 policy limit
If a higher limit is required, please advise:
a) Total sum insured
£
b) Number of machines
YES/NO
LOSS OF ALCOHOL LICENCE
IS COVER REQUIRED?
£50,000 Sum Insured
YES/NO
BUSINESS MACHINES ALL RISKS (cover inside & outside buildings)
Items Owned by the Cricket Club -not members personal items as these are excluded.
SUM INSURED
Club Cricket Bags and Contents. Minimum sum Insured £500.
Worldwide cover– New replacement cost. No claims excess.
£
Club Trophies & Engravings - New replacement cost. No Excess
Please provide a list & security arrangements if over £2,000
£
Cricket Equipment including artificial pitches, netting & poles, covers, sight screens and, bowling
machines. £25 Excess.
£
Laptop Computers and camera equipment (single article limit £1,500) Maximum Sum Insured £2,500
Please specify make, model and value of each piece of equipment below. £25 Excess
£
Groundsmens’ Equipment – cover in & outside buildings. Not included in Contents Section.
No Excess unless theft from the open or not involving forcible and violent entry or exit from a building
when the Excess will be £250.
Mowers #, Rollers #, Spikers #, Tractors # Tools. Implements & Fertilizers # (Market Value Applies)
£
Total value of all plant
machinery and tools.
Please give details below of all Machinery exceeding £1,000 in value
Make/Model
Serial No.
Item Value included
above
Make & Model of Laptops & Computers, Cameras and video recorders.
NB 1.
If you do not require cover for equipment whilst in the open, then please include the values of your equipment under the
Contents of Clubhouse Section. Cover under the Contents Section limits cover to items whilst in the building only and theft
must be by forcible and violent entry to or exit from the Buildings.
NB 2.
Theft of Groundsmens’ equipment left in the open is excluded unless the following precautions are undertaken
Motorised rollers and tractors
keys have been removed or the equipment is otherwise immobilised
All Other Equipment
a high tensile steel anchor concreted into the ground or secured to a building, by a
padlock
conforming to BS EN 12320 CEN Security Grade 4 or above and a chain approved to
‘Sold
Secure’ Gold (www.soldsecure.com)
PERSONAL ACCIDENT CAPITAL BENEFITS
Cover is available for Club playing members, including reserves, coaches and officials whilst playing or officiating in any organised
Club game, training, practice and whilst travelling directly to and from any match or practice.
Cover also given to Club members who undertake Voluntary Work involving groundsmens’ and associated work, maintenance work to
Club premises, Umpires, Scorers and preparing and serving Refreshments.
CAPITAL BENEFITS
IS COVER REQUIRED ?
Accidental Death
Permanent loss of sight in one or both eyes
Loss of limb(s)
Loss of Hearing in Both Ears
£25,000 (Limited to £2,500 for under 16s or those in full-time education)
£25,000
£25,000
£25,000
February 2014
YES/NO
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Loss of Hearing in One Ear
Loss of Speech
Permanent Total Disablement
Dental/Optical Treatment
Hospitalisation Expenses
TEMPORARY TOTAL DISABLEMENT
25% of Permanent Total Disablement Benefit
£25,000
£25,000
£750
Up to £10,000 subject to the following limits:
£50 per day for each completed 24 hours period, up to a maximum of 200
days should the Insured Person become hospitalised due to Bodily Injury.
Excluding the first 48 hours of each and every claim.
IS COVER REQUIRED ?
YES/NO
Weekly benefit is available in units of £20, with a minimum of £20 per week and a maximum of £200 per week
Please state amount of weekly benefit required
£
Rehabilitation Expenses
Up to £500 for Rehabilitation Expenses incurred due to Bodily Injury.
Excluding the first £20 of each and every claim.
Under 16’s are excluded for Temporary Total Disablement and adults must be in gainful employment and aged under 65.
DIRECTORS & OFFICERS INSURANCE – If this is required, please complete questionnaire below
GOODS IN TRANSIT £50 Excess
IS COVER REQUIRED
Limit any one vehicle Sum Insured £2,000
YES/NO
Excludes theft from unlocked vehicles and unattended vehicles at night.
CLAIMS HISTORY
Under the conditions of Your Policy You must tell us about any loss or damage during the last 5 years whether covered by insurance
or not Please give details below or state “None”.
CLAIMS IN THE PAST 5 YEARS
2013/2014
AMOUNT PAID OR
OUTSTANDING
£
2012/2013
£
2011/2012
£
2010/2011
£
2009/2010
£
YEAR
DATE OFPlease
INCIDENT
CLAIMany
DETAILS
CLAIMS EXPERIENCE
detail/ below
claims or losses occurring in the last 3 years.
DECLARATION – Please read the declaration carefully and then sign below
This Proposal Form will form the basis of Your contract with You and the Insurance Companies.
All material facts must be disclosed, failure to do so could invalidate the Policy. A material fact is one which is likely to influence
an insurer in the acceptance and assessment of this application. If you are in any doubt as to whether a fact is material then it should
be disclosed to the Insurer. If any change in circumstances arises during the period of insurance cover, provide your insurer with
details.
I confirm I am the named Club Official noted on this form. I/we declare that the information given in this Proposal Form is true and
complete to the best of My/Our knowledge and belief and that this Proposal Form and any additional information provided shall form
the basis of the contract between the Insurers and ourselves. I/We understand that if I/We have not given full and true answers to all
questions asked that Our insurance may not protect me/us in the event of a claim.
Signed
Position in Club ________________________
Print Name. Mr/Mrs /Miss
Date
/
/
Important.
We would recommend that you keep a copy of this Proposal form and any correspondence concerning your Insurance Policy
for your records.
February 2014
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DIRECTORS & OFFICERS INSURANCE QUESTIONNAIRE
Name of Assured/Club:
Your contact details:
Name
Address
Tel no & e-mail
Inception/Renewal Date:
Please Complete the Following:What was the Club or Society’s gross income/turnover for the last complete financial year?
£
Activities
Can you confirm that:



The Club or Society operates wholly within England, Scotland or Wales?
The Club or Society is either a sports, hobbies and interests, social, working men’s or welfare club or society?
The Club or Society
o
o
o
Does not promote, incite or is involved in any illegal activity?
Is not involved in any blood sports (other than angling) nor does the Club or Society represent the
interest of any persons involved in such activities?
Undertakes appropriate CRB checks and the like in respect of those working with Children
or vulnerable adults?
Yes / No
Management/Constitution
Can you confirm that:





The club or Society and its subsidiaries are solvent and are able to meet their financial obligations
and pay their debts as they fall due
The Club or Society or any of its subsidiaries does not provide any pension schemes?
Each member subscribes to the rules of the Club or Society and has equal voting rights?
There are no external (non-member) shareholders?
There are no plans presently under consideration by the Club or Society in relation to a material
change of ownership, management, constitution or the acquisition/sale of significant assets?
Yes / No
Declaration




Has the Proposer or any person insured or proposing for insurance been convicted or charged
but not yet tried, of any criminal offence other than a motoring offence?
Has the Proposer ever had an application for this type of insurance declined by an insurer, had
a renewal of such insurance declined, or had similar insurance cancelled or made subject to
special conditions?
Has the Proposer had any Clubs or Societies claims within the last 5 years?
Is anyone proposing for insurance aware, after enquiry, of any circumstance or incident,
which they have reason to suppose might afford grounds for any future claim such as would
fall within the scope of the proposed insurance which has not already been advised to Us?
Name:
Date
Yes / No
/
.
Official position in Club:
February 2014
Page 7