DARREN TEST of Capital Cover Combined Liability Submission

*Supporting CIRI - The Construction Industry Register of Ireland

Instructions : Please fill out and click submit at the end of this page. We only accept electronically completed submission forms.

WE DO NOT OFFER TERMS ON RISKS SUBMITTED ON RENEWAL DATE - PLEASE DO NOT COMPLETE THIS FORM IF THIS IS RENEWAL DATE. IT WILL NOT BE RESPONDED TO.

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***END OF YEAR WAGES & TURNOVER DECLARATION FORM CAN BE FOUND HERE***
NEW Combined Liability & Contractors All Risks Submission
Broker Name*
Broker Handler*
Broker E-mail*
Broker Direct Dial*

Area CodePhone Number
Are you the holding broker?*

YESNO
Date Quote Required*

DayMonthYear
Broker Address*
Legal Title of Proposer*
How long has the business been established*
Proposers Address*
Eircode
Business / Trade (AS REQUIRED ON POLICY)*
Description of work undertaken*
Are you a member of the CIF*

YESNO
Are you a member of CIRI*

YESNO
CIRI Number*
Does the proposer have an up to date Safety Statement?*

YESNO
Do you perform any roofing only contracts?*

YESNO
Do you engage in any hot roof work?*

YESNO
Do you perform any demolition only contracts?*

YESNO
Do you work in hazardous locations as outlined in our policy wording? (General Exclusion 9)*

YESNO
Does the proposer engage in any manufacturing / fabrication at their own premises?*

YESNO
What % of turnover would relate to these activities and give a description
Contract Details - complete at least one current or upcoming contract.
Contract 1*
Contract 1 Value*
Completion Date*

DayMonthYear
Contract 2
Contract 2 Value
Contract 3
Contract 3 Value
Other Details
Height & Depth Limits

Please confirm that all work undertaken by you will fall within the policy height and excavation limits selected below.
Height Limit Required:*

15M20M25MOther
Depth Limit Required*

3M4M5MOther
Limits of Indemnity (Employers Liability €13,000,000 As Standard)
Public / Products Liability Indemnity Required*

€6,500,000
Wages & Turnover Information
*Wages & Turnover figures should represent realistic projections for the intended annual period of insurance.*

The term payments to employees means the total wages, salaries, and other earnings without any deductions in respect of employee PRSI, USC, income tax, holiday pay or contributory pension.
Clerical / Non Manual Directors / Engineers
Manual working directors
Number of Manual working directors*
Foremen
General operatives
Number of General Operatives*
Plant hire / groundworks / light civil engineering
Heavy civil engineering
Woodworking Machinists - Fixed WWM
Payments to LOSC without own Insurance - i.e. labour gangs, labour only sub-contractors, self-employed sub-contractors
Payments to LOSC with own Insurance
TOTAL WAGES
Payments to Bona Fide Sub Contractors (With confirmed own Insurance) - Bona-fide sub-contractors are contractors who work without direction from the Insured, hold their own insurance and provide their own materials & tools.
TURNOVER (EXCLUDING PAYMENTS TO BFSC)*
TOTAL TURNOVER
Insurance History
Are you now or have you in the past 5 years been insured for similar risk? CHOOSE NO IF NEW BUSINESS*

YESNO
Please provide details of current / past Insurer*
Renewal Date*

DayMonthYear
Claims History
How many years claims free?*
Have any claims been made against you or incidents reported to you with in the last 5 years? *

YesNo
If Yes please outline claims below and attach confirmed claims experience

Upload a File

Cancelof
Include details of any outstanding Liability or CAR claims below if applicable.
Claim 1
Claim 2
Claim 3
Has any insurer declined to insure you, impose special terms, or refuse renewal?*

YesNo
More information
Contractors All Risks
Do you require a separate CAR quotation?*

YESNO
Do you build timber frame houses?*

YESNO
Maximum limit any one contract
Maximum contract period (Months)
Average contract period (Months)
Temporary building & contents
Maximum value of any one temporary building
Own construction plant tools & equipment
Maximum value of any one item of plant
Maximum value of any one items of hired in plant
Estimated hired in charges
Employees' personal effects / tools
Current Excess
Disclosure:

Any Material Fact must be disclosed to Insurers. i.e. Any information which may alter the judgment of an insurer in assessing the risk.Any material change must be disclosed to insurers. i.e. Any information which may alter the judgment of an insurer that has not previously been disclosed as material fact. Failure to provide all material facts and or notify of all material changes may cause the contract of insurance to be void and may result in Insurers repudiating liability entirely.
Broker Handler Full Name*

First NameLast Name
Date of Submission

DayMonthYear
PLEASE CLICK SUBMIT ONLY ONCE AND WAIT FOR YOUR CONFIRMATION MESSAGE
Should be Empty:

NEW Combined Liability & Contractors All Risks Submission

Contract Details - complete at least one current or upcoming contract.

Other Details

Wages & Turnover Information

Insurance History

Contractors All Risks