Farm
Proposal
Farm
proposal
Policy Number
P LE ASE ANSWER A LL QU ESTION S IN CA PITA L LETTERS
Name of Proposer in full:
Date of Birth
Phone
Postal Address:
Business or occupation:
(if more than one, state all)
Business for the purpose of this insurance
(Please state nature of farming engaged in e.g., Beef, Dairy, Tillage, Market Gardening or other)
Situation of property to be insured
(if different from Postal Address)
FOR OFFICE U SE ON LY
Period of insurance
FROM
Time
TO
Renewal Date
Area/Branch
Area/Branch Number
Agency
Agency No. & Chk Ltrs
Special notes:
Aviva Insurance Europe SE (‘we’, ‘us’, ‘our’) is your insurer.
As this is a package product, please choose at least one of the sections from 1-3 for
acceptance.
The insurance will not be in place until we have accepted the proposal. We have the right
to turn down any proposal.
For your and our protection, we may record and monitor phone calls.
Aviva Insurance Europe SE is regulated by the Central Bank of Ireland
PF.014.04.12c
Please answer all questions in CAPITAL LETTERS
General Questions
1
(To be answered by the proposer)
Are you at present insured in respect of any of the perils
or contingencies to which this proposal applies? If so, state
class of insurance and name of insurer.
YES
NO
If YES – Please give details
(a) Do you now hold a Farm Insurance Policy?
(b) Have you previously held a Farm Insurance Policy?
2
To the best of your knowledge and belief have you or any
other person(s) material to this risk
(a) Been convicted of any offence of any nature or is any
prosecution pending?
(b) Been refused any insurance, renewal or had any special
terms or conditions imposed by any insurer?
(c) Been involved in any accident or loss or have any claims
been made against you or them in the last five years?
(d) Defective vision or hearing or suffering at any time from
diabetes, fits, any heart complaint, any other disease or
physical infirmity?
3
Are you involved in poultry rearing or cattle dealing on a
commercial basis?
4
Do you hold livestock auctions on your farm?
5
Do you take in paying visitors? If “Yes”, please state
the maximum number applicable at any one time, and
whether this activity is carried out on a seasonal basis only
or all year round.
6
Is any other party (e.g. building society or bank) interested
in the property proposed for insurance?
7
Do you engage in other agri-linked activities?
8
Is your machinery properly guarded and otherwise in good
condition?
9
Is there a sand-pit or quarry on your land?
10
Are all fields abutting the public road and neighbouring
farms properly fenced?
11
Have you prepared a written safety statement, in accordance
with the Safety, Health and Welfare at Work Act, 2005?
12
Have you any other insurance with Aviva?
(if Yes, please give details)
13
Are you a member of either of the
following organisations (Please Indicate)
ICMSA
ICSA
If not you should do so immediately in the interest of safety and to avoid prosecution. To
assist you, the information booklet “Guidelines on Safety Statements” is obtainable from
the Health and Safety Authority or any Teagasc office.
REMINDER
Property should be insured for its full value. Option B of Section 1
and each item of Section Nos. 2 and 3 will be subject to average
that is if the sum insured at the time of loss is less than the value of the
property insured, you bear a proportionate share of the loss.
Section 1
Farmhouse and Contents
YES
NO
Do you require cover? (The house must be owned and occupied by you.)
Description of farmhouse
Please indicate scope of cover required by ticking the appropriate box.
BUILT OF
OPTION A: “HomeCover” the complete Insurance Package for your
home Buildings/Contents/Frozen Foods
ROOFED WITH
Do you require “All Risks” cover?
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Limit any one Article - €1,300
OR
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Limit any one article - €2,000
Please specify the sum insured on Buildings
Minimum of €75,000
The sum insured should be based on rebuilding costs plus an amount sufficient to
include Architects’ and Surveyors’ Fees (usually 12.5% of the value of the Buildings)
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Description
€
Value
A
B
C
D
Please indicate the sum insured on Contents (Option A only)
i.e. 50%, 40% or 30% of Buildings sum insured above
OPTION B: The economic alternative
i.e. Restricted cover Fire, lightning, explosion, aircraft and earthquake
Sum Insured on Contents – 50% of Buildings
Is the farmhouse fitted with an alarm system conforming to
EN50131?
%
YES
NO
Is the farmhouse fitted with two smoke detectors?
Are you aged 50 or over?
If Yes give details
Is the farmhouse especially exposed to the risk of, or has it any history of
damage by storm, flood, water, subsidence, landslip and/or ground heave?
Is the dwelling left unoccupied:(i)
for sixty consecutive days in any one period of insurance?
(ii)
regularly on a daily basis?
Height of mast
Do you wish to include TV or Radio Aerial over 8 metres high?
metres
Farmhouse (2) and Contents
YES
Do you require cover? (The house must be owned by you and occupied
by a member of your immediate family.)
Please indicate scope of cover required by ticking the appropriate box.
OPTION A: “HomeCover” the complete Insurance Package for your
home Buildings/Contents/Frozen Foods
NO
Description of farmhouse
BUILT OF
ROOFED WITH
Do you require “All Risks” cover?
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Limit any one Article - €1,300
OR
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Limit any one article - €2,000
Please specify the sum insured on Buildings
Minimum of €75,000
The sum insured should be based on rebuilding costs plus an amount sufficient to
include Architects’ and Surveyors’ Fees (usually 12.5% of the value of the Buildings)
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Description
€
Value
A
B
C
D
Please indicate the sum insured on Contents (Option A only)
i.e. 50%, 40% or 30% of Buildings sum insured above
Is the farmhouse fitted with an alarm system conforming to
EN50131?
OPTION B: The economic alternative
i.e. Restricted cover Fire, lightning, explosion, aircraft and earthquake
Sum Insured on Contents – 50% of Buildings
Is the farmhouse fitted with two smoke detectors?
Are you aged 50 or over?
If Yes give details
Is the farmhouse especially exposed to the risk of, or has it any history of
damage by storm, flood, water, subsidence, landslip and/or ground heave?
Is the dwelling left unoccupied:(i)
for sixty consecutive days in any one period of insurance?
(ii)
regularly on a daily basis?
Do you wish to include TV or Radio Aerial over 8 metres high?
Height of mast
metres
%
YES
NO
Section 2
General Farm Property
FIRE, LIGHTNING, EXPLOSION, AIRCRAFT, RIOT, CIVIL COMMOTION, MALICIOUS DAMAGE, IMPACT, EARTHQUAKE AND SUBTERRANEAN FIRE
YES
NO
Do you require cover?
Please specify Sum Insured in respect of each item
1
ROOTS and POTATOES not stored in buildings
€
2
SILAGE in open or in detached buildings or in towers of incombustible construction and used for no other purpose
€
3
AGRICULTURAL PRODUCE and FARMING STOCK, including hay straw and growing crops but excluding livestock and the aforementioned
N.B. Agricultural produce within 20 metres of a chimney in use - unless in buildings which are completely enclosed - is not
covered
4
5
6
7
€
POULTRY REARING HOUSES
€
€
POULTRY
FARM IMPLEMENTS and MACHINERY your property or for which you are responsible excluding power driven vehicles, implements and
their accessories if and so far as they are otherwise insured
€
BUILDINGS OF ALL FARM OUTBUILDINGS - (except as specially mentioned below), constructed of brick, stone, concrete, slates, tiles,
metal or slabs composed entirely of incombustible mineral ingredients
N.B. Give details below of any outbuildings of construction other than that outlined above or of any buildings for which separate insurance
is required. Insert sums insured in respect of such outbuildings or “Nil” if cover is to be excluded.
DESCRIPTION AND PURPOSE FOR WHICH USED
BUILT OF
ROOFED WITH
VALUE
A
€
B
€
C
€
D
€
E
€
F
€
TOTAL OF ALL FARM OUTBUILDINGS
€
Please give details of any other property not specified above.
€
TOTAL
8
Fire Brigade charges are included (up to a maximum of €10,000) across sections 1, 2 or 5 if insured.
€
€
Section 3
Livestock
YES
BASIC COVER APPLICABLE:-
A
NO
Do you require cover?
Loss of or injury to livestock as a result of Fire Lightning Explosion Aircraft and Earthquake
ADDITIONAL COVER OPTIONS – Fatal injury to livestock:
B
caused by Electrocution
C
as a result of accidental violent external and visible means whilst the animals are On or Straying from your farm premises or Being Driven or Led on Foot on any
public thoroughfare. Also accidental injury or death to livestock as a result of collapse of slatted units.
D
as a result of accidental violent and visible means whilst In Transit on any public thoroughfare in suitable vehicles including loading and unloading and attendance
at any sale or show on land within the Republic of Ireland or Northern Ireland
E
resulting directly from Dog Attack or Worrying by Dogs (Sheep only)
Please specify sums insured and other details for each category of livestock to be insured. Basic Cover A is mandatory for each category insured, you should therefore indicate
additional covers chosen by inputting B C D or E as required in Additional Cover Options column. Note Cover E only permitted when all other additional cover options
B C and D are also chosen.
Category
No. of
Animals
Maximum Value any
one Animal*
Sum
Insured
Cattle
€
€
Sheep
€
€
Pigs
€
€
Horses
€
€
€
€
Additional Cover
Options
*NB limit any one animal €6,500.
Section 4
Liabilities
YES
A EMPLOYERS LIABILITY
NO
Do you require cover?
Schedule of Remuneration
All persons employed must be included. For the purposes of calculating the premium, board and lodgings must be assessed at the actual values but not less than the
figures provided by the agricultural wages (minimum rates) order.
1
Please complete the following details in full, excluding members of your family and household.
NUMBER
WAGES INCLUDING PRSI
BOARD AND LODGINGS AND
ALL OTHER ALLOWANCES
TOTAL
FULL TIME
PART TIME
ALL OTHER PERSONS
HIRED OR BORROWED BY
THE PROPOSER
TOTAL 1
2
Do you require members of your family and/or household to be included
If “Yes” please complete the following details in full.
FAMILY AND/OR
HOUSEHOLD MEMBERS
NUMBER
YES
NO
YES
NO
Do you require cover?
WAGES INCLUDING PRSI
BOARD AND LODGINGS AND
ALL OTHER ALLOWANCES
TOTAL
FULL TIME
PART TIME
TOTAL 2
3
Please state total wages etc. paid to employees engaged in agricultural contract work.
N.B. Agricultural Contractors as a trade are not acceptable.
4
Do any of your employees:
YES
If “Yes” give details
NO
(a) Work in a sandpit or quarry?
(b) Use circular saws or other machinery driven
by mechanical power?
(other than agricultural vehicles)
B
PUBLIC LIABILITY
Do you require cover?
State (a) Total acreage including con acreage
(b) Total number of horses/ponies if any and purposes for which they are kept
Section 5
1
Agricultural & Forestry Vehicles
Vehicle(s)
REGISTERED LETTERS AND NUMBER
OR ENGINE NUMBER
2
DESCRIPTION, INCLUDING MAKER’S NAME AND TYPE
Trailer(s)/Implement(s)
DESCRIPTION
YEAR OF
MANUFACTURE
DATE OF
PURCHASE
BY PROPOSER
PROPOSER’S ESTIMATE OF PRESENT PLEASE STATE COVER REQUIRED I.E.
VALUE INCLUDING ACCESSORIES COMPREHENSIVE, THIRD PARTY FIRE
AND SPARE PARTS*
& THEFT, THIRD PARTY ONLY
Third party attached cover automatically applies; if you need greater cover you must give full details of all trailers
IDENTIFICATION MARKS
PROPOSER’S ESTIMATE OF PRESENT VALUE PLEASE STATE COVER REQUIRED I.E.
INCLUDING ACCESSORIES
COMPREHENSIVE, THIRD PARTY FIRE
AND SPARE PARTS*
& THEFT, THIRD PARTY ONLY
*In the event that the Vehicle is damaged beyond economic repair, we will calculate the value of the vehicle at the time of the loss on the basis of the current market
value (for a vehicle of the same make and model) or where applicable the limit of the value (sum insured) placed by you on the vehicle as shown on the policy schedule,
whichever is less. Please note: We will not pay for loss or damage over the current market value even if the sum insured on the policy schedule may be greater.
Section 5
3
Driver(s)
Agricultural & Forestry Vehicles (contd.)
Give the following details in respect of all persons who to your knowledge may drive
NAME
AGE
OCCUPATION
GIVE DETAILS IF CONVICTED
DURING THE PAST 5 YEARS
OF ANY OFFENCE IN
CONNECTION WITH ANY
STATE PERIOD OF
REGULAR DRIVING ON MOTOR VEHICLE OR IF ANY
PROSECUTION IS PENDING
FULL IRISH LICENCE
YES
RECORD OF ACCIDENTS
DURING PAST 3 YEARS
OF DRIVING
NUMBER
COST
HAVE ANY INSURERS
REFUSED HIS / HER MOTOR
INSURANCE OR IMPOSED
SPECIAL TERMS?
GIVE DETAILS OF ANY
DISEASE OR PHYSICAL
INFIRMITY OR DEFECTIVE
VISION OR HEARING
NO
If Yes give details
4
Will the vehicle(s) be used for:Anything other than agricultural and forestry purposes?
5
Will you use your vehicle(s) outside the Republic of Ireland?
6
If you have chosen Third Party Fire & Theft
Do you require “Windscreen Cover” option?
7
Has a Statutory safety frame been fitted to all vehicles?
8
Is any vehicle implement or trailer to be used at any time for
(a) hire or reward?
(b) treefelling?
(c) haulage of trees on the road?
9
Do you require the drivers’ fatal accident benefit?
i.e. €26,000 in the event of accidental death of any person
authorised to drive under the Policy, occurring whilst a
driver of any motor vehicle insured under this section.
Section 6
Bulk Milk Storage Installations
YES
Cover Available (please note cover 2 can only be chosen in conjunction with cover 1)
1
NO
Do you require cover?
Accidental damage to storage installation. Please complete the following details:Manufacturer
Capacity in
Gallons
AGE*
Maintenance Contract
in Force (yes/no)**
Sum Insured
€
€
€
*NB-maximum age 10 years **NB-Maintenance Contract must be in force and provide for a minimum of twice yearly inspections
2
Deterioration of milk contained in above installation(s). Please complete following details:How often is your milk collected?
Maximum value of milk stored at any one time
Section 7
€
Business Interruption
YES
Do you require cover?
Cover Options
1
NO
Loss of Gross Income and Increase in Cost of Working in the event of the farming activity being interrupted as a result of a claim insured under
Section 2 (General Farming Property):Sum Insured (i.e. Gross Income)
2
€
OR
Additional Expenditure in consequence of a claim insured under Section 2, which is necessary to maintain the farming activity on the pre-loss scale:Sum Insured (i.e. Additional Expenditure)
€
Period for which indemnity is required? _______________ months following date of loss/damage.(If longer than 12 months then sums insured should be adequate
to cater for the period selected)
Section 8
Tax Legal Protection
YES
This section provides cover for Accountants Fees and Expenses and Legal Costs and Expenses to represent
you in an in-depth investigation by Revenue Commissioners into your business accounts. Limit of Indemnity €150,000.
Do you require cover?
NO
Section 9
Personal Accident
YES
Note cover only available for you or a member of your family and where the Occupation of the person to be insured
is that of: Farmer, Spouse, or Farmer and Agricultural Contractor (where contracting constitutes less than 50% of the duties).
NO
Do you require cover?
Summary of Cover: One Unit (up to 20 units per person can be chosen).
Bodily injury resulting in:
Death or loss of one or more limbs or eyes or Permanent and Total Disablement. .........................................................
€3,900
Temporary Total Disablement ................................................................................................................................................
Inability from engaging in usual occupation for a period of up to 104 weeks from the date of injury.
€30 per week
after first week of disablement
Temporary Partial Disablement ..............................................................................................................................................
Inability from attending to a substantial and essential part of usual occupation for a period of up to 26 weeks
from the date of the injury.
€15 per week
after first week of disablement
Vouched Medical Expenses .....................................................................................................................................................
To the best of your knowledge and belief have you or any of the persons proposing:
up to €650
Name of Person to be Insured
Duties (describe in full)
YES
(a)
Any physical or other defect or weakness of any kind
(b)
Had any injuries, diseases or illness
NO
Date of Birth
No. of Units
/
/
/
/
/
/
/
/
If YES, please give FULL details.
OR
Important
You must tell us any other facts which are likely to affect whether we agree to provide cover, or how we assess the risks proposed for insurance, including but not limited to:
a) Previous insurance claims
b) Any convictions, offences or prosecutions pending of any nature (for example, but not limited to, fraud, theft, penalty points, driving convictions, or the handling of stolen goods)
c) Medical details or history (when this information is specifically requested under a section) and
d) The main user of the vehicle or any vehicle modifications (applicable to motor risks only)
If you are not sure whether you should tell us about something, please tell us anyway. This is for your own protection because, if you do not give us all the information we need, your policy may not
provide you with the cover you need, a claim may not be paid, the policy may be declared invalid and void or may be cancelled, and you may encounter difficulty trying to purchase insurance elsewhere.
You should also be aware that failure to have property insurance in place could lead to a breach of the terms and conditions attaching to any loan secured on that property.
Warning: As it is an offence under the Road Traffic Act to make any false statement or withhold information to get a certificate of insurance, you should make sure that you answer all questions
fully and accurately. If the proposer is a firm or a private company, you must read and answer the questions as though they also apply to each individual partner or member.
Under the third EU Non-life Directive we must give you the following information before you buy your policy.
The law that applies to the contract - Under the relevant European and Irish laws, we Aviva Insurance Europe SE and you, the proposer, are free to choose the law that will apply to the
contract. We propose that Irish law will apply to the contract. We, Aviva Insurance Europe SE, will provide the insurance under this policy.
Complaints procedure - We aim to give excellent service to all our customers; however, we recognise that things may occasionally go wrong. We will do our best to deal
with your complaint as effectively and quickly as possible. If you arranged your cover through an agent or adviser, please send your complaint to them. If your complaint is not
sorted out to your satisfaction, please contact:
Customer Feedback Team, Aviva Insurance Europe SE, One Park Place, Hatch Street, Dublin 2
CallSave:
E-mail:
Website:
1850 36 37 38
[email protected]
www.aviva.ie
You can also write to the Managing Director, Aviva Insurance Europe SE, One Park Place, Hatch Street, Dublin 2 or you can contact the following
UÊ The Irish Insurance Federation’s Insurance Information Service, 39 Molesworth Street, Dublin 2
Phone:
Fax:
E-mail:
Website:
01 676 1914
01 676 1943
[email protected]
www.iif.ie
U The Financial Services Ombudsman Bureau, 3rd Floor, Lincoln House, Lincoln Place, Dublin 2
Phone:
LoCall:
Fax:
E-mail:
Website:
01 662 0899
1890 88 20 90
01 662 0890
[email protected]
www.financialombudsman.ie
You will not lose your right to take legal action if you contact either of the above.
DATA PROTECTION - Aviva Insurance Europe SE (“we”, “us” or “our”), as data controller, will keep the information you provide about yourself and about third parties confidential.
We may use it to advise on, provide and administer insurance products and financial services provided by us or other Aviva companies and sometimes with our affiliates and/or
commercial partners, in order to comply with legal obligations imposed on us. We may share the information both inside and outside of the European Economic Area, in confidence,
for these purposes with agents or service providers we have appointed, private investigators, regulatory organisations, other insurance and financial services companies (directly or via
a central register), other Aviva group companies, those to whom we outsource certain business operations and as required by law. We will process this information and store it on our
computer and manual record systems.
To assist in preventing, detecting and/or protecting our customers and ourselves from theft and fraud, we may use your information to make searches of our or other Aviva companies’
records. If you give us false information or fail to disclose information and we suspect fraud, we will record this. We also participate in industry databases such as those operated by
the Irish Insurance Federation for the purpose of sharing of information among insurance companies as a check against non-disclosure.
From time to time, we may record your telephone calls for verification and training purposes.
If you would like a copy of the details we hold about you, please write to the Regulation and Compliance Manager, Aviva Insurance Europe SE, One Park Place, Hatch Street, Dublin 2.
Please enclose the correct fee (€6.35). You also have the right to correct any errors in the information held about you, block certain uses or object to the processing of your personal data.
Important: Some of the questions on this form may ask for details about your health and convictions and the health and convictions of third parties material to this risk – please do not
send us any genetic test results. This information is important for underwriting and claims purposes and will remain confidential. By signing the declaration below, you are giving us
permission to process these details for the above purposes, including checking with third parties or accessing State or other official records to verify whether the details you have given
are accurate and complete. By signing below, you are confirming that you have fully explained to each person who requires this insurance cover why we asked for this information and
what we will use it for. You are also confirming each person has agreed to this.
ONLY SIGN THE FOLLOWING DECLARATION IF YOU FULLY UNDERSTAND, AND HAVE MET, ALL OF THE ABOVE REQUIREMENTS.
Declaration – I/We confirm that, all the details, answers and information given in this proposal are true, accurate and complete. I acknowledge that this proposal will form the basis of
my/our contract with Aviva Insurance Europe SE. I/We confirm that I/we am/are giving my/our permission to you to use the information I/we have given on this form for the purposes
set out in the Data Protection section above.
Your Signature:
Date:
/
/
We would like to use your details to provide you with information about other financial or insurance products, services and special offers either from us or other Aviva
group companies, or products, services and special offers which any member of the Aviva Group may arrange with a third party. Your details may also be used for this
if you do not wish to receive such information from us.
purpose (for up to 12 months) after your policy has ceased. Please tick here
Your choice will not affect any of the services we provide to you, now or in the future.
Aviva Insurance Europe SE Registered in Ireland No 3319 Registered in Ireland No 374895 Registered office: One Park Place, Hatch Street, Dublin 2.
Aviva Insurance Europe SE is regulated by the Central Bank of Ireland