Commercial Express: Contractors All Risk
Proposal / statement of fact
EUNISURE ADVISER'S NAME
*
Name of the Insured
*
Client Name
Business Proprietor/Director Name
*
Trading Name(s)
*
Address for correspondence for the insured
*
Street Address
Street Address Line 2
City
County
Postcode
Date of Birth
*
/
Month
/
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Best Contact Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What year did the insured start trading?
(YYYY)
Insured's business
Address of business to be insured
Street Address
Street Address Line 2
City
County
Postcode
Select a trade that best matches the business in question
Does the above trade match exactly the insured's trade?
Yes
No
Are you unsure as to the suitability of the risk?
Yes
No
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Are there any activities undertaken in /at:
Farms?
Yes
No
Chemical and /or Gasworks?
Yes
No
Oil refineries, Power Stations?
Yes
No
Aircrafts, Airports, Watercraft?
Yes
No
Offshore Installations?
Yes
No
Do activities involve:
Application of heat?
Yes
No
Construction or renovation of timber framed buildings?
Yes
No
Bridgework - any building of bridges or suspended structures?
Yes
No
Work in, over or adjacent to water?
Yes
No
Directional drilling, pipe jacking or tunneling?
Yes
No
The use of Tower Cranes?
Yes
No
Is the maximum height of buildings worked on over 10 metres?
Yes
No
Is the maximum excavation depth more than 2 metres?
Yes
No
Sums insured
Section 1: Contract works
Maximum Contract Price (any one contract)
£
Maximum Contract Length (any one contract)
Annual Contracting Turnover
Excess
Section 2: Owned Plant
Do you wish to extend cover to Section 2 - Owned Plant?
Yes
No
Owned Plant Sum Insured (New Replacement Value)
£
Owned Plant Limit of Indemnity (Any one Accident)
Excess
Section 3: Hired in Plant
Do you wish to extend cover to Section 3 - Hired in Plant?
Yes
No
Estimated Annual Hire Fees
£
Hired in Plant Limit of Indemnity (Any One Accident)
Excess
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Section 4: Employees tools and personal effects
Do you wish to extend cover to Section 4 - Employees Tools & Personal Effects?
Yes
No
Total Sums Insured (Limit to GBP 500 per Employee)
£
Excess
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Disclosure and claims
History: Please answer the questions below in respect of the applicable parties described in (i) (ii) (iii) and (iv) below. If you feel unable to answer a question(s) accurately or have a material fact or circumstance(s) to disclose please provide full details in the additional information box at the bottom.
(i) Ever had insurance cover refused or cancelled or special terms imposed?
Yes
No
(ii) Any Director or Partner
Yes
No
(iii) Any person(s) with a beneficial interest of 25% or more in the business (other than mortgages)
Yes
No
(iv) Any person with management control of the insured
Yes
No
Has the insured:
a) Ever had insurance cover refused or cancelled or special terms imposed?
Yes
No
b) Ever been convicted or cautioned with any criminal offence, other than driving offences?
Yes
No
c) Ever been prosecuted under the Health and Safety at Work Act, the Consumer Protection Act and/or any other statutory regulations?
Yes
No
d) Ever had any claims or incidents at these or any other premises in the last 5 years?
Yes
No
e) Been declared bankrupt, incurred a County Court Judgement(s) that remains unsatisfied or entered into an individual voluntary arrangement with creditors?
Yes
No
f) Ever been disqualified from acting as a Company Director?
Yes
No
g) Been a director of a company or partner of a business that:
i) went into liquidation, administration, or was subject to an insolvency process or scheme of arrangement with creditors?
Yes
No
ii) incurred a County Court Judgement(s) that remains unsatisfied?
Yes
No
Additional Information
Submit
Should be Empty: