Commercial Express: Contract Cleaners

Commercial Express: Contract Cleaners
Proposal / statement of fact
Disclosure
IMPORTANT NOTICE: Please check this proposal/ statement of fact for insurance very carefully.

Please answer the questions set out below accurately and completely. For your convenience, we have included certain answers in the form however you must change these answers if they are inaccurate. This may result in Commercial Express or the Insurers requiring further underwriting information, but may not preclude Commercial Express or the Insurers from providing cover. This does not modify your/ your client's duty to disclose all material facts. You must answer all questions accurately and completely. You must provide us with all further information we request and any other information of which we should be made aware.
Insured
The following proposal/ statement of fact, together with any information supplied to the insurers, will form the basis of the Insurance and any non-disclosure or misrepresentation of a material fact could invalidate all or part of the Insurance contract.

Please do not note the interest of any third party in the Name of the Insured field. Any third party interests to be noted can be entered during the quotation process..

A material fact is a fact likely to influence insurers assessment of the risk. If you are in any doubt as to what constitutes a material fact you should consult your colleagues or Commercial Express.
Adviser Name *
Name of the insured *
Address for correspondence for the insured *
Address including Postcode
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Phone Number *
Best Contact Time *

: Hour Minutes AM/PM Option
What year did the Insured start trading? *
Business Proprietor/Director Name *
Business Address *
Address including Postcode
Insureds business
Select a trade that best matches the business in question:
Trade Type
Does the above trade match exactly the insured's trade?
Are you unsure as to the the suitability of the risk?
Is the maximum height of buildings worked upon more than 10 metres?
Does the insured have any business activities: Outside England, Scotland, Wales or Northern Ireland?
Does the insured undertake or intend to undertake any activities on or at:
i) Hospitals or farms?
ii) Chemical or Gasworks?
iii) Oil refineries or Power Stations?
iv) Aircrafts, Airports, Watercraft?
v) Offshore installations?
Sums insured

Cover required:
Public/ Products Liability:
£
Annual Turnover:
up to £
Employers Liability:
£
Optional covers

Business Equipment (Anywhere in the UK) whilst contained in a vehicle or stored within the Insured's premises
Business Equipment Sums Insured
£
Do you wish to extend the cover to theft from an unattended motor vehicle and whilst on site?
Stock cover whilst contained in a vehicle or stored within the insured's premises
Stock Sum Insured
£
Do you wish to extend the cover to theft from an unattended motor vehicle?
Policy extensions

Do you wish to extend the policy cover to include:
Financial Loss (in the event that the assured becomes legally liable to pay for financial loss by others)?
Lock and /or Key Replacement (in the event of losing or replacing a locking device to a third party property)?
Misuse of Telephones (in the event that the insured shall become legally liable to pay due to any act of fraud, dishonesty, or embezzlement in connection with the misuse of customers telephones by an employee of the insured)?
Treatment (in the event of liabilities arising from accidental bodily injury or accidental damage to property caused or rising from any treatment carried out by the insured or their employees)?
Excesses
Public / Products Liability at the premises:
£
Material Damage (Optional Covers):
£
Policy Extensions
As per special conditions?
Employer reference number (ERN) / Employer PAYE reference

Only a very tiny minority of employers that do noy pay salaries through PAYE are exempt from providing an ERN. All employers who pay PAYE must provide an ERN,
Is the company exempt from having an ERN?
Disclosure and claims

Has the Insured:
a) ever had Insurance cover refused or cancelled or special terms imposed?
b) ever been convicted or cautioned with any criminal offence, other than driving offences?
c) ever been prosecuted under the Health and Safety at Work Act, the Consumer Protection Act and/ or any other statutory regulations?
d) ever had any claims or incidents relating to this or any other business in the last 5 years?
e) ever been declared bankrupt or been the subject of any winding up petition or order in this or any previous business?
Additional Information: Any further information or material facts you should or would like to advise Underwriters?
Yes or No-If Yes give details
I confirm on behalf of myself and my client that I have fully read and understood: i) the introductory statement; and ii) the above questions and informayion; I confirm that I have raised all appropriate queries and performed all appropriate due diligence with my client in this regard.

Yes
Should be Empty:

Commercial Express: Contract Cleaners

Proposal / statement of fact

Disclosure

Insured

Insureds business

Does the insured undertake or intend to undertake any activities on or at:

Sums insured

Optional covers

Stock cover whilst contained in a vehicle or stored within the insured's premises

Policy extensions

Excesses

Employer reference number (ERN) / Employer PAYE reference

Disclosure and claims