Quantum Insurance

Disclosure
Personal
Business
Finish

Disclosure

This product meets the demands and needs of those Business proprietors who wish to have cover in place to protect their assets and earnings. Your Schedule and Statement of Fact shows the cover you have selected. The choices you have made will depend on your personal circumstances.

You should check your Schedule and Statement of Fact carefully to ensure you have the required cover. This statement does not form part of the terms and conditions of your policy.

This Statement of Fact forms part of your insurance contract. It is a record of answers specifically provided to ourselves, and also of some Your Schedule and Statement of Fact shows the cover you have selected. The choices you have made will depend on your personal circumstances. The information recorded in this document has been material to our assessment of :

1) your eligibility for this policy;

2) the terms and conditions applying to your policy;

3) your insurance premium.

Please check this form immediately. If any of the information is incorrect please call your broker on their usual number - failure to do so could invalidate the policy from inception or result in a claim being repudiated. You or any of your partners or directors either personally or in connection with any business which you/they have been involved have never:

a. been declared bankrupt or are the subject of any current bankruptcy proceedings or any voluntary or mandatory insolvency or winding up procedures? * Yes No
b. been disqualified from being a company director? * Yes No
c. had a County Court Judgement or Sheriff Court Decree? * Yes No
d. been convicted or have any prosecutions pending or been given an official police caution, in respect of any criminal offence other than motoring offences? * Yes No
e. been prosecuted or have prosecutions pending under the Health and Safety at Work Act or any other statute or regulation? * Yes No
f. had any insurance proposal declined, renewal refused, had any special or increased terms applied or had insurance cancelled mid-term by Underwriters? * Yes No

Personal Information

Name *

Surname *

Company Name or Trading Name *
Phone *
E-Mail *
Address *
Street Address
County
City

Post code
How many years have you been trading? *
What date would you like cover to begin? *
Trade *
Is there any manual work away from the premises other than collection & delivery? * Yes No
Is there any work at height or depth or in enclosed spaces? * Yes No
Do you or any of your employees engage in the application of heat either on or away from the Business premises? * Yes No
Do you or any of your employees handle, transport or work with any of the following: Radioactive substances or devices, explosives, asbestos, silica, toxic or hazardous chemicals, materials giving rise to dust or fumes, lifts, cranes, hoists, slings, cradles or processes involving a noise level in excess of 85db? * Yes No
Do you or any of your employees work on, manufacture or sell products used in aircraft, spacecraft, marine craft, offshore, in nuclear installations, in safety critical parts, motor vehicles or railways? * Yes No
Do you design, give advice or prepare specifications in respect of any products supplied or contract? * Yes No
Do you maintain rights of recourse/recovery against any manufacturer? * Yes No
Do you have a formal written Health and Safety policy? * Yes No
Do you have less than 5 employees? * Yes No
Have you carried out the following risk assessments in respect of the Management Of Health And Safety At Work Regulations 1999: ? a) manual handling b) COSHH c) working with machinery d) work at heigh * Yes No
Do you have a formal safety-training plan for employees? * Yes No
Do you have a document procedure for high-risk activities? * Yes No

Additional Information

theatre Plays are played in private event rooms and Halls at different locations.

Employers Liability limit required * £10M No
Public Liability limit required *
Is Products Liability cover required? * Yes No
Do you require cover for Legal Expenses? * Yes No
Do you require Tools cover ? * Yes No
Within the last 5 years, have you or any of your partners or directors in connection with any business which you/they have been involved had any losses whether insured or not or had any claims made against you? * Yes No
- Description
Estimate Annual Turnover
£
UK
£
USA/Canada
£
Rest of the World
£
Payments to bona-fide subcontractors
£
Number of Employees
Clerical Principals/Directors
Manual Principals/Directors
Clerical staff/LOSC's
Manual staff/LOSC's
Estimated Annual Wagerolls
Clerical Principals - non manual labour
£
Clerical Employee's - non manual labour
£
Manual Principals
£
Manual Employee's - Drivers / Yardsmen
£
Manual Employee's -All other
£
Labour only subcontractors
£

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Tradesman Public Liability Insurance

Disclosure

Personal Information

Additional Information

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