PUBLIC LIABILITY-PROPOSAL FORM
Please complete all of the questions in this Proposal Form continuing the answers on your
headed notepaper where there is insufficient space. A Director, Partner of the Firm and/or
Manager authorised to do so must sign and date this Proposal.
1.
Names of Companies proposed to be insured (including all Associated and/or Subsidiary
Companies)
2.
Principal Address
3.
Please describe the nature of the business operations and identify any special features
4.
Please state description (i.e., shop, office, factory, warehouse) and address of premises to be
insured
5.
Please give details of your turnover broken down between home and overseas market
Home
(a)
Actual turnover for the past 12 months
(b)
Estimated turnover for the next 12 months
Overseas
Total
6. a) Do you undertake work away from your premises?
YES/NO
If ‘Yes’ please give full details including relative salaries
and/or wages
7.
b) Do you require Work Away extension under the policy?
YES/NO
(i)
YES/NO
Is any work undertaken by sub-contractors on your behalf?
If ‘Yes’ please state nature of work and give details
of estimated annual turnover
(ii)
8.
Are hold-harmless agreements obtained in all cases?
Do you have any mobile plant and/or vehicles
not licensed for road use?
YES/NO
YES/NO
If ‘Yes’ please give full details
9.
Do you have any goods/passenger lifts, cranes, hoists,
boilers and/or other vessels under steam pressure?
YES/NO
If ‘Yes’ please give full details
10.
Are acids, gases, spirits, petrol, oils, petrochemicals, plastics
or explosives or other hazardous substances used or stored?
YES/NO
If ‘Yes’ please give full details
11.
Do you wish to insure against liability arising from
goods sold or supplied?
If ‘Yes’ please give full details
YES/NO
12.
Are you presently insured for Public Liability risks?
YES/NO
If ‘Yes’ please give full details of Insurer/Insurers and cover
provided or supply a copy of the existing Insurance Policy
13.
In respect of Public Liability Insurance, has any
Insurer ever cancelled or refused to renew your cover?
YES/NO
If ‘Yes’ please give full details
14.
List the claims experience for the past five years to which this proposal form would apply
Year
Settled Claims
Numbers
15.
Amount
Outstanding Claims
Numbers
Amount
Are you aware of any incidents that may result in claims against you?
If ‘Yes’ please give full details
YES/NO
16.
Please indicate level of indemnity requireda) Any one Accidentb) Annual Aggregate-
17.
Please indicate the territorial scope of liability required-
___________________________________________________________________________
18. Please indicate the Jurisdiction required-
DECLARATION TO BE SIGNED BY A DIRECTOR, PARTNER OF THE FIRM AND/OR
MANAGER AUTHORISED TO DO SO
All questions must be answered correctly and in full before a quotation will be given.
Failure to disclosed material facts could result in your policy being invalidated. Material facts are
those facts which might influence the acceptance or assessment of your proposal. If you are in
any doubt as to whether a fact is material, you should disclosed it.
I/We hereby declare that the above statements are true and complete and I am/We are not aware
of any further material information which should be disclosed to the Company and I am/We are
willing that these replies shall be taken as the basis of the contract between me/us and the
Company.
Signature:…………………………………………….
Title:…………………………………………………...
Date:…………………………………………………...
Signing this Proposal/Form does not bind either the Proposer or Underwriters to complete a
Contract of Insurance.
A copy of this Proposal should be retained by you for your records.