Commercial Express: Hobby and Club

IMPORTANT NOTICE: Please check this proposal/statement of fact for insurance very carefully

The proposal/statement of fact, together with any other information supplied to the Insurers must not be misleading or incomplete and shall from the basis of the contract with the Insurers and shall be incorporated therein. If you are aware (having made all due enquires) of any information not specifically in the proposal/statement of fact but which may have a material bearing upon the Insurer's decision on whether ot not to provide cover or the terms upon which such cover would be provided, you must notify the Insurer via yur intermediary of it before the contract of Insurance is concluded and obtained their specified conformation that they are willing to proceed. You must inform Insurers via your intermediary of any material alteration or additions to the statements or particulars contained within this proposal/statement of fact, which occur before any contract of Insurance based on this proposal/statement of fact is effected.

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 misrepresentaion of a material fact could invalidate all or part of the Insurance contract.
A material fact is a fact likely to influence insurers assignment risk. If you are in any doubt as to what constitutes a material fact you should consult your colleague or Commercial Express.

Adviser Name *

Full Business Name *

Trading Name *

What year did you start Trading? *

Correspondence Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Business Address *

Street Address

Street Address Line 2

City State

Zip Code

Email

example@example.com

Select the trade that best matches the business in question:

Does the above trade match exactly the insured trades?

Yes No

Outside England, Scotland Wales or Northern Ireland?

Yes No

i) Hospitals or Farms?

Yes No

ii) Chemical or Gasworks?

Yes No

iii) Oil refineries or Power Stations?

Yes No

iv) Aircraft's, Airports, Watercraft?

Yes No

v) Offshore installations?

Yes No

Public/Products Liability £

Employers Liability limit £

Please provide the number of members for the club:

Do you require cover for All Risks away from the premises?

Yes No

Public/Products Liability at the premises £

Public Liability (work away) £

Professional Indemnity £

Is the company exempt from having an ERN?

Yes No

a) Ever had insurance cover refused or cancelled or special terms imposed?

Yes No

b) or insured family member ever been convinced or cautioned with any criminal offence, other than driving offences?

Yes No

c) Ever had any claims or incidents at these or any other premises in the last 5 years?

Yes No

d) Been prosecuted under Health & Safety at Work Act, Consumer Protection Act or other relations?

Yes No

e) Ever been declared bankrupt or been the subject of any winding up petition or order in this or any previous business?

Yes No

Any further information or material facts you should or would like to advise Underwriters?

Yes No

I can confirm i have read and understood all the questions relating to this quotation. *

Yes No

Commercial Express: Hobby and Club

Disclosure

Insured

Insured businesses

Does the above trade match exactly the insured trades

Does the insured undertake or intend any activities on or at

Sums insured

Cover required

All risks

Excesses

Employer reference number (ERN) / Employer PAYE reference

Disclosure and claims

Additional information