Public Liability Insurance Proposal Form

A. PERSONAL DETAILS

UNLESS SPECIALLY MENTIONED POLICIES DO NOT COVER INJURY OR DAMAGE CAUSED BY HOISTS OR CRANES. SEPARATE POLICIES MUST BE EFFECTED IF IT IS DESIRED TO COVER LIABILITY IN RESPECT OF CYCLES OWNED BY THE PROPOSERS HORSEDRAWN OR MECHANICALLY PROPELLED VEHICLES, PASSENGER LIFTS OR BOILERS

Proposer's Name (in full)

Address

Tel

Trade or Business (full description)

B. OFFICES, SHOPS, WAREHOUSES AND INDUSTRIAL RISKS

Please State

1. Number and Description of Good Lifts, Hoists and Cranes

(a) are they insured under seperate Policy?

(b) if not, do you enquire Third Party Cover under this insurance?

2. Are any of the cranes or hoists in the public thoroughfare? if so, give particulars

3. Particulars of Trap Doors, Cellar Flaps, or other openings in floor or pavement

C. RESTAURANTS AND CLUBS

4. State seating capacity of Restaurant

5. State nature of Club and number of Members

D. THEATRES, CONCERT AND PUBLIC HALLS, AND ALL PLACES OF AMUSEMENT

6. State the capacity of Theatre, Hall etc in number of persons

7. Are Refreshments served? and if so is the service under your own management?

8. What Sideshows or other Entertainments are provided?

9. Give description (Day, Boarding, Private etc)

E. GENERAL INFORMATION (applicable to all the above)

10. Indemnity required for any one accident ¢

Indemnity required for the period

Note* In view of the increasing cost of Third Party claims a substantial indemnity is desirable

11. FOOD POISONING: Do you desire the risk of Ptomaine Poisoning to be included?

12. What machinery have you with which persons not in your service can come into contact, and what is the motive Power?

13. Do you use or store any explosive, chemicals, chemical gases or radioactive substances?

14. Do you employ sub-contractors? If you wish the Policy extended to Indemnify you for your liability, please state estimated annual contract prices of sun-contracts.

15. Have any claims been made upon you by persons not in your employment? If so, please give particulars.

16. Are you at present insured, or have you ever proposed for an insurance in respect of this risk? If so please give name of the Company.

17. Has any such Proposal ever been Declined or Withdrawn?

18. Has any Company or Underwriter at any time

(a) Refused to renew

(b) Cancelled your Policy

19. Have you any other Policy with the Company? If so, please quote Department

20. Address of the Premises to which the policy is to apply

21. Do you undertake work elsewhere than on your Premises? If so, state fully its nature and whether you require cover under the Policy for such work.

22. State

(a) Estimated Annual Amount of Wages and Salaries paid to Employee (excluding Clerical Staff) and Number of Employees ¢

(b) Estimated Annual Earning of any Principal Director or Partner who will engage in manual labour ¢

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Public Liability Insurance Proposal Form

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