Online Public Liability Proposal
The questions on this form and any other questions which we specifically ask, relate to facts considered material to underwriting the insurance. If you answer them fully and honestly you will be considered to have fulfilled your duty to disclose material facts. Failure to do so may invalidate your insurance. A copy of the completed proposal form will be supplied on request, but you should keep a record (including copies of letters) of all information supplied to us for the purposes of entering into this contract. A specimen policy is available on request.
The Proposer
Title
First Name
Last Name

Address:
Business Address:

Description of Premises
Indemnity Limit Required:
Home Telephone
Work Telephone
Email Address
 
Proposer's Business
Full Description of your activities:
Date established:
What machinery or electrical appliances will be used:
Are the premises, plant, equipment and machinery in sound condition and will they be so maintained: Yes No
If 'no' give details:
Will acids, gases, chemicals, explosives or corrosives be stored, handled or used: YesNo
If 'yes' give details:
Will chemical effluent or fumes or anything of a noxious nature be discharged: Yes No
  If 'yes' give details including precaut ions being taken to prevent pollution:
Will any radioactive substances or other sources of ionising radiation be handled or used: Yes No
If 'yes' give details:
Will you undertake any manual work away from your premises (other than delivery) Yes No
  If 'yes' state nature of this work and total estimated wages applicable for next 12 months: (Please also answer questions a, b & c below)

Will any of this work:

    
  a) Be outside the country: Yes No
 
if 'yes' give details & estimated wages
applicable for next 12 months:
  b) Involve the use of welding, flame-cutting equipment or blowlamps: Yes No
 
If 'yes' state nature of work and estima ted
wages applicable for next 12 months:
  c) Be sub-contracted to:    
 

i) Established firms:

 Yes No
 

ii) Others (including self-employed persons):

 Yes No
 
if 'yes' give details & estimated payments
applicable for next 12 months:
Are you represented in any form (ie: Branch Office, subsidiary or associated company, sales office, agent holding power of attorney) in any other country: Yes No
 
if 'yes' give details:
 
Proposer's Products
Give details of products supplied, sub-divided into different categories if more than one type of product is involved, (if not apparent, include purpose of use). Note: Hardcopy specimen brochures or leaflets for each product will be required. Also, state estimated annual turnover relating to each category of product:
How long have you been manufacturing or supplying the different categories of products supplied:
Are you acting as: Retailer Wholesaler Assembler Manufacturer Importer

Will you supply any products that you do not manufacture:

 YesNo
 

if 'yes'...

  
 
Do you retain rights of recovery
against the manufacturer
 Yes No
 
Do you alter, adapt, or change the form of any product which you do not manufacture:
 Yes No
 
if so, give details, including the product involved, purpose of use, nature of supplier and type of alteration, adaptation or change made:
 
Give details of imported products including purpose of use, source and estimated turnover applicable for next 12 months for each:
Will any of your products be used....  
  In aircraft or aerial devices of any kind: Yes No
  In offshore installations: Yes No
 
if 'yes' to either question, state purpose of use and estimated turnover applicable for next 12 months for each:
What types of containers are used and are they manufactured by you:
Do you have any contracts or agreements with any customers, suppliers or sellers (Note: Hardcopy evidence will be required): Yes No
Will you provide any services or treatments other than the supply of products: Yes No
  If 'yes' Give details and estimated turnover applicable for next 12 months:
What system of check is in operation for the purpose of discovering possible defects in products:
What are the major hazards associated with the products you supply:
Have you warned users of these hazards: (If 'yes', please supply labels leaflets or instructions): Yes No
Will you design, give advice on or prepare specifications for any product you supply: Yes No
  If 'yes' give details including products involved and design staff qualifications and experience:
  (Also supply hardcopy extracts of relevant sections of design manual if available)
     
Exports (to countries other than USA and Canada)
Will any of your products be directly exported, or have any previously been directly exported to countries other than USA or Canada: YesNo
 

If 'yes' give details of the products, the destination country and, if they are presently being exported, the estimated turnover for the next 12 months:
   
Exports to USA and Canada
Will any of your products be exported, or have any previously been exported to USA or Canada:
  Directly by you or on your behalf: Yes No
  Indirectly:  
 
As components supplied to other manufacturers
for export to USA or Canada:
 Y es No
 
In any other way whereby to your knowledge they become exports to USA or Canada whether or not in the form in which you originally supplied them:
 Yes No
  If 'yes' give details. In the case of Indirect Exports, please indicate the form in which the product is or was supplied by you and it's final form as an export to USA or Canada:
 
 

Please state for USA and Canada (separately) the turnover of each product applicable to each of the last three years and the estimated turnover for the next 12 months:
 
Product Type Year Turnover
USA Canada
Estimated turnover for next 12 Months:
  Is Insurance arranged on your behalf in USA or Canada in respect of Products Liability: Yes No
 
If 'yes' give details:
  How long have you been a supplier of products to USA or Canada:
 
Your Insurance Requirements
Please complete as necessary:    
Description of all employees
Wages but not fees of working
directors should be included)		 Estimate number Estimated wages and salaries
for next 12 months
At your premises Away from your premises
Clerical and Administrative only
(not engaged in manual work)
All others (Specify below:)      
Total Estimated wages and salaries for next 12 months:
Total estimated turnover for next 12 months
 
Risk History
Have any incidents occurred during the last five years resulting in injury (including death, disease or illness) to members of the public or damage to their property arising out of:
  Your general operations: Yes No
  Products supplied by you: Yes No
 

 

 if 'yes' give details:  
   
Date of Occurrence Brief details of incident Cost (if any) of claim paid Estimated outstanding
Has proposer previously insured against Public or Products Liability: Yes No
  If 'yes' give details including name of Insurer:
Has any insurer in respect of the risks to which this proposal relates ever:
  Declined a proposal, refused renewal or terminated an insurance: Yes No
  Required an increased premium or imposed special conditions: Yes No
    if 'yes' to either question above, give details:
       
Declaration
I hereby declare that, to the best of my knowledge and belief, the particulars and answers are true and correct and that I have not withheld any information which is likely to influence the decision of the Company in regard to this proposal. Submitting this form does not bind the proposer to complete the insurance but it is agreed that this form shall be the basis of the contract should the policy be issued. No liability attaches to the Company until this proposal has been accepted – Tick to agree to the declaration:
 
 
   
Public Liability Insurance:
Cover Provided
  This policy provides cover up to a selected Limit of Indemnity in respect of the insured's liability at law to pay damages and claimants' costs and expenses to members of the public as a result of:
 
  • Accidental bodily injury (including death, disease and illness) to persons
  • Accidental loss of or damage to material property arising in connection with the insured's business (other than property in the insured's care, custody or control)
 

The Limit of Indemnity is usually the maximum that the company will pay in respect of all claim s for injury or damage resulting in one cause or event.
In respect of all claims resulting from products supplied, it is also the maximum that the company will pay in any one year.

The company also pays the insured's costs incurred with it's written consent in defending or settling claims.
Exclusions
  The policy does not generally cover:
 
  • Injury or damage in connection with foul berthing, the ownership, possession or use of locomotives, aircraft, aerial devices, hovercraft, water-borne craft or mechanically-propelled vehicles
    (Note: The policy, however, may be amended in some cases to include vehicles such as fork-lift or dump truck and the like which are used normally at the insured's place of work and the use of which does not require compulsory third party motor insurance)
  • Damage to any structure or land due to vibration or to the withdrawal or weakening of support.
  • Injury to employees
  • Additional liabilities assumed by agreement by the insured
  • Risks of a professional nature
  • Any consequence of war or kindred risks or contamination by nuclear fuel or waste
 

In addition there are certain other exclusions but the policy will be framed to meet the special needs of the insured as far as possible 

Premiums
 

The premiums vary according to the information given, including the nature of the business, the number of premises, amount of wages, turnover and the Limit of Indemnity required. A quotation will be given on receipt of a satisfactory proposal together with any further information which may be required .