Tree Surgery Insurance, Arboricultural Insurance, Tree Surgeon Liability Insurance, Commercial Vehicle Insurance, Fleet Insurance - Trust Insurance

The completion of this form in no way binds the Proposer to purchase insurance, nor does it bind Underwriters to give insurance.

Any information given will only be passed to Underwriters for the purpose of quotation and will be treated as confidential.

NAME/S (Including trading names) of the proposer/s:

Name

Date Commenced

Website Address

Email Address

Telephone Number:

ADDRESS/ES of Proposer/s:
All Addresses must be shown together with the Principal responsible for the work at each office:

Address

Principal in charge

Is cover required for predecessor practices to the proposer/s?

Yes	No

If yes please provide full details:

Name of Predecessor	Date commenced	Date Ceased	Reason for Ceasation

Name in full of all principals	Qualifications	Date Qualified	How long as a principal with proposer/s

Please state the name of any Professional body or trade association of which the proposer is a member

Professional Body

Trade Association

Is cover required for the previous business activities of any principal?

Yes	No

If yes please state:

Name of principal

Name of previous firm

Name of principal
Name of previous firm
Period From
Period to
Fees for last 3 yrs

Reason for leaving
Position in firm
Is there seperate insurance covering the activities of this firm for the period stated above?

Is cover required for any past partner or principal?

Yes	No

If yes please give:

Name	Qualifications	How long with proposer/s

Please state total numbers of:

Principals

Contract Hired Staff

Qualified Staff

Others

Name of current insurers

Name of your broker

Renewal Date

Limit of Indemnity

Premium

Excess

Please provide a full description of all of your activities:

Please categorise the activities outlined above and indicate the approximate percentage of the gross income/fees each represents:

%

%

%

%

%

%

%

%

Do you anticipate any major changes in these activities in the forthcoming 12 months?

Yes	No

If yes please give full details:

Where do you perceive your exposure to claims to lie? In what circumstances might you envisage a claim arising?

Have you undertaken any other activities in the past for which cover is required?

Yes	No

If yes please give full details:

Are you involved in any process of manufacture, construction, alteration, repair, installation or sale or supply of products other than in a pure consultancy capacity as described above?

Yes	No

If yes please give full details:

Is any work put out to sub contractors?

Yes	No

If yes please state:

What percentage of gross income/fees was paid to sub-contractors in the last financial year?

%

Are sub-contractors required to carry professional indemnity insurance?

Yes	No

Do you get an indemnity from sub contractors in writing?

Yes	No

If yes to what limits?

Do you require any sub-contractor to be indemnified under your insurance arrangements?

Yes	No

If yes please state:

Name	Qualifications	Fees paid last financial year

State for the whole proposer/s:
Gross income/fees received for each of the last five financial years

			Last complete year	Current year estimate	Forthcoming year estimate
Year End(£)
UK work(£)
USA/Can(£)
Other Overseas(£)
Total (£)

Please give details of the 3 largest contracts in the last 5 financial years (give details of current projects if new business)

Client	Start Date	Description	Total Contract Value	Fee	Approximate Completion Date

What is the total fee income received in the last financial year from your largest client?

What is the average fee received in the last completed financial year?

Have you at any time undertaken any work where the 'end product' is situated outside the United Kingdom?

Yes	No

If yes please give the following details

Country	Start date	Description	Total Contract Value	Approximate Completion Date	Serviced Provided

Do you work other than from its UK offices?

Yes	No

Have you at any time accepted liability other than under the jurisdiction of the UK courts?

Yes	No

If yes to either then please provide full details listing jurisdiction and amount of work involved below

Do you use a standard form of contract, agreement of letter of appointment?

Yes	No

Do you commit your clients to contracts with third parties?

Yes	No

If yes do you always obtain clients written acceptance of the terms of contracts before committing them?

Yes	No

If no please provide details

Are you or have you been a member of a consortium or group practive or engaged with any other party in a single project partnership.

Yes	No

If yes please give full details (including names of other parties) special arrangements must be made to cover this type of work

Does the Proposer/s or any principal have any association with or financial interest in any other practice, company or organisation?

Yes	No

If YES give full details of the nature of the association together with the name and business of the third party.

Do you require insurance for:

Loss of documents

Yes	No

Dishonesty of Employees

Yes	No

Libel and Slander

Yes	No

Breach of Copyright

Yes	No

Unintentional Breach of Confidence

Yes	No

Claims involving Pollution etc

Yes	No

Some Policies give this cover automatically

For what limit/s of indemnity are quotations required?

There wil be a minimum level of uninsured excess. Is a quotation required with a voluntary excess to achieve a premium saving? If so, for what level of excess?

IN respect of ANY of the risks to which this proposal relates has any claim been made (whether successful or not) against the proposer, any predecessor or any past or present principal.

Yes	No

Has any loss been suffered by the proposer, any predecessor or any past or present principal in respect of ANY of the risks to which this proposal relates?

Yes	No

If YES please give details:

Date of claim/loss	Brief details of claim/loss	Cost of Claim/loss	Estimated cost of claim/loss outstanding

What steps have been taken to prevent a recurrence?

Is any prinicipal AFTER FULL ENQUIRY aware of:

Any circumstances which might give rise to a claim against the proposer, any predecessor or any past or present principal?

Yes	No

Any circumstance which might cause any loss to the proposer, any predecessor or any past or present principal?

Yes	No

Any matter which might otherwise affect the consideration of this proposal for insurance?

Yes	No

If YES to any of the above, please give details:

Has any proposal for similar insurance made on behalf of the proposer or any of the present of past partners, directors or principals or on behalf of any predecessor to the proposer ever been declined or has any such insurance ever been cancelled or renewal refused.

Yes	No

If YES, please give details:

Please read this paragraph carefully before signing the decleration:

It is essential that every proposer or assured when seeking a quotation to take out or renew any insurance discloses to the prospective underwriters all material facts and information (including all material circumstances) which might influence the judgement of an underwriter in deciding whether to accept the risk and on what terms. The obligation to provide this information continues up until the time that there is a completed contract of insurance. Failure to do so entitles the underwriters, if they so wish , to avoid the contract of insurance from inception and so enables them to repudiate liability. If you have any doubt as to what constitutes a material fact of circumstance please fo not hesitate to ask for advice.

DECLARATION

I/we declare that, after full enquiry, the contents of this proposal are true and that I/we have not misstated, omitted or suppressed any material fact or information. I/we agree that this proposal together with any other information supplied by me/us shall form the basis of any contract of insurance which may be effected. If there is any material alteration to the facts and information which I/we have provided or any new material matter arises before the completion of the contract of insurance, I/we undertake to inform underwriters.

I/we hereby consent to any information I/we have provided being processed by you for the purposes of providing insurance and claims handling, which may neccessitate sharing such information with third parties. HCC International Insurance Co PLC may use this information for marketing (by post, telephone, email or fax) subject to the conditions of the Data Protection Act. If you do not wish these details to be used for marketing please inform HCC International Insurance Co PLC in writing. Under the Data Protection Act 1998 you have the right to access or amend the information we hold about you. If you would like to exervice either of these rights please contact HCC International Insurance Co PLC/

Tree Surgery Insurance, Arboricultural Insurance, Tree Surgeon Liability Insurance - Trust Insurance

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