CommerCial Combined for Trade and indusTry - AXA … · CommerCial Combined for Trade and indusTry...

CommerCial Combined for Trade and indusTryProposal FormMay 2015 Edition

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Important Notice

You and we can choose the law which applies to this policy. We propose that the Law of England and Wales apply. Unless we and you agree otherwise, the Law of England and Wales will apply to this policy.

Law Applicable to Contract

To apply for the Commercial Combined for Trade and Industry Policy, please complete this Proposal Form in BLOCK CAPITALS using a ball-point pen (blue or black ink).You must complete all parts of this Proposal Form in all cases. Insurance begins when AXA Insurance has accepted your application.You must give full and true answers to all questions. If you do not do so your insurance cover may not protect you in the event of a claim. You should keep a record of all information supplied to AXA Insurance (including copies of correspondence).

If the space provided is inadequate please supply full details using the Additional Information Section.

Correct Values at risk must be advised to us. If the Sums Insured that you request are not adequate this will result in the amount that we pay you in the event of a claim being reduced.

A copy of this Proposal can be supplied on request, within a period of 3 months after its completion.

A copy of the Policy is available on request.

AXA Insurance UK plc is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.

PART A – Your Business Details

1 Full Title of Proposer and Subsidiary Companies to be included in this insurance (Please give full names of partners if not a Limited company)

2 Postal Address

Trading Name (if different from above)

Postcode

3 Telephone number

4 Contact name and position within company

5 Trade or Business

6 Operative Dates

7 Do you wish to pay the premium by instalments? If ‘Yes’ please complete a Budget Plan Application

8 When established

9 Please detail membership of any Industry, Trade or accreditation body

Cover Required from

Renewal Date

The liability of the Company does not commence until acceptance of the Proposal has been confirmed by the Company

(DD/MM/YYYY)

(DD/MM/YYYY)

Yes No

(DD/MM/YYYY)

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1. Are any additional interests to be endorsed on the Policy, e.g. Bank?

Yes No

If you tick a shaded box 3 please give details. If the space provided is inadequate, use the Additional Information section or continue on separate sheet(s).

General Questions

If ‘Yes’ please provide name, address and postcode

a) at the premises to be insured?

2. How long have you been in business:

b) at any other premises? Years

Years

3. Are you the sole occupier of the premises? Yes No

4. Are the premises in good repair internally and externally and will they be so maintained?

5. Have you or any of your partners or directors either personally or in connection with any business in which you have been involved

a) previously held insurance for any of the covers to which this Proposal relates at these premises or elsewhere?

Yes No

Yes No

If ‘Yes’ please advise name of Insurers and Policy number

b) held any insurances (in respect of the covers to which this Proposal relates) which have subsequently been

i) declined? Yes No

ii) terminated? Yes No

iii) refused renewal? Yes No

iv) subject to special terms? Yes No

c) ever been convicted or charged (but not yet tried) with a criminal offence other than a motoring offence?

Yes No

d) ever been declared bankrupt or are the subject of any current bankruptcy proceedings or any voluntary or mandatory insolvency or winding up procedures?

Yes No

e) ever been the subject of a recovery action by Customs and Excise or the Inland Revenue?

Yes No

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f) had within the last five years any losses whether insured or not or had any claims made against you (in this or any existing or previous business)? If ‘Yes’, please complete the claims experience box on page 5

6. Are there any other material facts you should disclose?

A Material Fact is information that may influence the Company in the acceptance of this insurance and the terms provided

Yes No

Yes No

Question No. Details

7. Are you applying for Employers’ liability insurance as part of this policy?

Please provide the following information for the insured business and all its subsidiaries to be covered by this policy. As your quote includes Employers’ liability insurance, the Financial Conduct Authority requires us to capture your Employer Reference Number (ERN). This number is essential for the Employers’ Liability Tracing Office to help employees trace their employer’s insurer if they ever need to make a claim in the future.

Yes – please fill in this section No – please go to next section

8. Please enter the Employer Reference Number (Employer PAYE reference) for your organisation.

This will have been sent to you by HM Revenue & Customs and is in the format 999/AA12345.

If you don’t have an ERN, please write ‘not yet known’ here. Please tell us the number as soon as you have it.

/

9. If you don’t have an ERN, are you exempt from holding?

If NO please write ‘not yet known’ here. Please tell us the number as soon as you have it.

NB Exemption will generally be only where staff are paid less than the PAYE threshold.

Yes No

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Yes – please enter the ERN for each subsidiary and their address details below. Please continue on additional sheets if necessary.

No – please go to the next page.10. Does your organisation have any subsidiaries with their own Employer Reference Numbers?

Name of subsidiary

Subsidiary’s ERN (Employer PAYE reference)/

Yes No – please fill in the first line of the address below.

Is this subsidiary registered to the same address as the parent company?

Name of subsidiary




Name of subsidiary




Name of subsidiary




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Claims Experience

Date of Occurrence

Claim Type (See below)

Brief details of each incident (Whether a claim was made or not)

Cost

Paid or Outstanding

Please detail below any losses within the last five years whether insured or not in respect of any of the covers to be insured under this policy.

Claim Type codes

MDI = Material Damage THE = Theft BII = Business Interruption ELI = Employers Liability PLI = Public Liability PRO = Products Liability MON = Money SAR = All Risks GIT = Goods in Transit LEG = Legal Expenses FGY = Theft By Employees

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PART B – Cover Options

Property

Cover Required1. All Risks

or

2. Specified Perils

If you have selected specified perils, please tick the appropriate boxes to indicate cover required

Note

i) Cover for malicious damage will only be considered where riot cover is also requested

ii) Cover for flood will only be considered where storm cover is also requested

3. Theft following entry to or exit from the premises by forcible and violent means

Yes No

Yes No

Yes No

4. Do you require the Day One Average extension?

If ‘Yes’, please tick the inflation percentage required

Yes No

storm

escape of water

flood

explosion

riot

impact

sprinkler leakage

aircraft

malicious damage

earthquake/subterranean fire

+15% +20% +25% +30% +50%

Cover RequiredSUMS INSURED Please make sure your Sums Insured allow for:

Buildings• Landlords fixtures and fittings• Architects surveyors legal and consulting engineers fees• Outbuildings• Walls gates and fences• Yards car parks and pavements• Pipings ducting cables wires and associated control gear on the premises extending to the public

main but only to the extent of your responsibility• Fixed glass• Debris removal costs

Contents• Machinery and plant• Legal and consulting engineers fees• Property held in trust• Tenants improvements• Debris removal costs• Contents of outbuildings• Contents of open yards covered

Stock and Materials in Trade• Property held in trust• Debris removal costs

REINSTATEMENT VALUE The Sum Insured under Buildings and Contents should represent the reinstatement value as losses will be settled on this basis unless we advise you to the contrary on acceptance of this Proposal.

� Theft is not covered

Basis of Cover - Please refer to Policy Summary of Cover

Under this Section you should select the cover you require by ticking the appropriate boxes below.

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Section 1 – Material Damage

Premises And Sums To Be Insured Standard construction means premises built of brick stone or concrete and roofed with slates tiles concrete metal asbestos or sheets or slabs composed entirely of incombustible mineral ingredients and plastic roof lights

1. Premises Insured

Postcode

2. Sums Insured

a) Buildings

b) Contents

c) Stock

d) Other Property (please specify)

Factory

Warehouse

Office

Other - please specify

4. a) Are the premises of standard construction?

b) If ‘No’ are the premises lined with combustible wall linings or sandwich panels?

If ‘Yes’ please advise details of extent and type

c) If ‘No’ to (a) and (b) please give details

5. Heating

Please state method of heating premises

6. Are the premises in a position or area likely to be subject to flooding or where flooding has occurred?

3. Occupation

How do you occupy the premises? (tick as appropriate)

£

£

£

£

Yes No

Yes No

If insufficient space is provided for your answers please use the Additional Information Section on Page 23.

If you tick a shaded box 3 please provide further details

Phone no (if different from that provided under Your Business Details

Yes No


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Section 2 – Theft

1. Premises Insured

The cover will apply to the same addresses as those listed in the Material Damage Section

c) Portable tools

£

£

£

£

a) Contents (excluding property in b) c) d) and e) below)

2. Sums Insured

b) Stock

d) Electronic office equipment (i.e. computers and peripheral equipment, fax machines, photocopiers and word processors)

Premises And Sums To Be Insured

Yes No Are any items included under d) valued in excess of £5,000?

If ‘Yes’ please list these with values on page 23

e) Other Property (please specify) £

10. Additional Premises

Are any additional Premises to be insured?

If ‘Yes’, please complete additional premises information sheet(s)

Yes No

7. Has the electrical installation been inspected by a qualified engineer during the last 5 years?

8. Are you the sole occupier of the premises?

9. Do you wish to extend your cover to include Subsidence?

If ‘Yes’

a) Has the property or any adjacent property previously suffered damage from subsidence?

b) Are there visible signs of cracking?

c) Is the property erected on made up ground?

d) Are there trees within 5 metres of the property?

e) Are there any elm, poplar or willow trees within 10 metres of the property?

If a structural survey has recently been carried out please attach a copy

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


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Section 3 – Business Interruption and Accounts Receivable

Premises And Sums To Be Insured

1. Premises Insured

The cover will apply to the same addresses as those listed in the Material Damage Section

2. Sum Insured

a) Estimated Gross Profit

c) Accounts Receivable

b) Additional Expenses only (Increased Cost of Working)

3. Uninsured Working Expenses

Please list the expenses you are not insuring under item 2a): bad debts purchases and

4. Maximum Indemnity Period

Please state Maximum Indemnity Period required

£

£

£

months (min 12 months)

4. Additional Premises

Are any additional Premises to be insured?

If ‘Yes’, please complete additional premises information sheet(s)

Yes No

3 Are the premises protected by an intruder alarm?

If ‘Yes’

a) Name of installer

b) Method of signalling

Bells only

Digital communicator

BT Redcare

Other- please specify

Yes No

Where the indemnity period exceeds 12 months the sum insured should be increased proportionately.


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4. Premises (other than your own) where property is stored

Postcode

5. Premises of any public supply undertaking from which you obtain electricity, gas, water, or telecommunications services

Yes % of Estimated Gross Profit

6. Goods in transit

7. Motor vehicles

8. Do you wish to cover loss resulting from theft or attempt thereat?

The Optional Extensions Listed Below Are Available

If you answer ‘Yes’ to questions 1, 2 & 4 please give full name and address including postcode

If you require cover please indicate 3

1. Suppliers premises

Postcode


2. Customer premises

Postcode


3. Premises where contracts are carried out Yes % of Estimated Gross Profit




Cover Required

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Section 4 – All Risks – Selected Articles

Details of Articles to be Insured

Sum Insured £

Please indicate cover required by ticking box 1, 2, 3 or 4

1 Europe

2 Great Britain

3 Insured premises only

4 Worldwide


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Section 5 – Money

Limits Limits Required

Estimates1. Estimated annual amount of notes and coins

in transit

For any loss of Money (other than crossed cheques and cancelled National Insurance stamps)

2. From the premises out of Business Hours in the undernoted locked safe or strongrooms Show makers name and model number

£

1. In transit or in a bank night safe or from the premises during Business Hours £

3. From the premises out of Business Hours or at the residence of any principal or authorised employee £500 maximum per premises Maximum amount of money carried by one person

£

£

£

2. Does the above include money relating to all your premises? If the answer is ‘No’ please specify why

Personal Accident – Assault Do you wish to increase the benefits from £5,000 (capital sums) and £50 (per week)?

Yes No

Yes No

Yes No

If the answer is ‘Yes’, please state limits required (maximum £10,000 capital sums and £100 per week)

1. Capital sums

2. Temporary total disablement (weekly benefit)

£

£

£

General QuestionsGive full details of precautions taken for the safety of the money a) at the premises or sites

(excluding money in a locked safe)

b) in transit

2. Will the money be in the possession of collectors or roundsmen?

If the answer is ‘Yes’, please state the maximum amount held


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Yes No

Please tick appropriate box to indicate the cover required LIMIT OF INDEMNITY

Employers Liability £10,000,000

Yes NoDo you wish us to consider a higher amount?

If ‘Yes’ please specify amount

Yes NoPublic Liability with Product Liability

For Product Liability insurance, this is the limit for any one period of insurance£

Yes NoPublic Liability without Product Liability

£

£

Your BusinessPlease give details of work undertaken

Please indicate the Limit of Indemnity required

Please indicate the Limit of Indemnity required

Liability


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Section 7 – Public/Product Liability

£

Wageroll of all employees (which includes labour masters, labour only persons or persons supplied by them, self employed persons or persons hired or borrowed) and Working Principals, directors or partners

a) Working on your premises

£ b) Working away from your premises and involving the use of heat

£ c) Working away from your premises not involving the use of heat

2. Other payments

£ a) Payments to sub-contractors working away from your premises

£ b) Charges for plant/equipment hired in

3. Turnover of your business for sales and/or services

£ a) Within the UK

£ b) Within the USA and Canada

£ c) Elsewhere in the World

Section 6 – Employers Liability

£

Wageroll of all Employees (which includes labour masters, labour only persons or persons supplied by them, self employed persons or persons hired or borrowed)

1. Clerical staff (including commercial travellers and managerial employees who do not engage in manual labour)

£2. Woodworking machinists and their labourers

Employers whose work with woodworking machinery is restricted to the use of lathes, fret-saws, boring machines, sanding machines and mechanically-driven portable hand tools (other than pendulum and swing saws) may be included under ‘all other employees’

3. All other employees working on own premises (please provide details of work undertaken)

£4. All other employees working away from own premises (please provide details of work undertaken)

£

EstimatesBasis of Cover - Please refer to Policy Summary of Cover

Please give details of your estimated turnover, wages and other payments for the next 12 months.


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General Questions – Liability1. Does your trade or business involve the discharge

of effluent, fumes or anything of a noxious nature?

Yes No

2. Do you have any facilities for mooring, berthing, loading or unloading water-borne craft?

Yes No

3. Are your premises in a good state of repair? Yes No

4. Is your machinery and plant (including mechanically propelled plant) properly fenced, guarded and in good order and where appropriate inspected in accordance with statutory requirements?

Yes No

5. Do you handle, use, store or transport any of the following?

a) asbestos or silica or materials containing these substances

Yes No

b) isocyanates Yes No

c) dioxins

d) radioactive substances or other sources of ionising radiations

e) acids, gases, chemicals, explosives, or other toxic, dangerous or waste substances

Yes No

Yes No

Yes No

6. Do you work on or in aircraft or on aircraft operational areas, water borne craft, off-shore or nuclear installations, petro-chemical works or power stations?

Yes No

7. Do you use oxy-acetylene or similar welding or flame cutting equipment, angle grinders, blow lamps or blow torches, flame guns, hot air guns or other heat producing equipment?

9. Are you aware of the requirements of the Health and Safety at Work etc Act 1974 and do you complete workplace risk assessments in accordance with Section 3 of the Management of Health and Safety at Work Regulations 1999?

Yes No

Yes No

Yes No

10. Has any prosecution, prohibition notice or improvement order been made against you under any Health and Safety legislation during the last 5 years?

Yes No

8. Is there a written Health and Safety Policy in place, which is regularly updated, and are all employees aware of its content?

11. Do you undertake manual work outside the UK? Yes No

12. Do you offer professional advice or services or undertake any form of treatment?

Yes No

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5. Do you enter into any contracts or agreements which may affect your liability under Statute or Common Law? (please provide copies of agreements/contracts if you do)

Yes No

Product Liability Questions1. Please give details of the following, including description and use

a) manufactured products

b) other products sold and supplied

c) work or services undertaken away from your premises

2. Have you any assets or representation or any associated or subsidiary operation outside the UK?

Yes No

3. Will any of your products be supplied directly, or to your knowledge indirectly, to USA/Canada?

Yes No

4. Do you import any products, materials or components?

If ‘Yes’, state the percentage of turnover from

a) EC countries

b) elsewhere

Yes No

%

%

If you have ticked a shaded box 3 please give details below

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6. Are there circumstances where you

a) would be unable to identify your supplier?

b) would be unable to enforce rights of recourse against your supplier?

c) are requested to provide an indemnity to customers?

7. Do you undertake to provide design specification, formula or advice

a) in connection with your products?

b) separately for a fee?

Yes No

Yes No

Yes No

Yes No

Yes No

8. Are any products intended for installation in or to form part of aircraft, water borne craft, off-shore installations, nuclear installations, petro-chemical works or power stations?

9. Do you subscribe to any recognised quality standard?

10. Do you have a system in force for checking quality control?

11. Are any of the products that you manufacture or supply knowingly sold, altered, serviced, processed or tested in the automobile industry ?

Yes No

Yes No

Yes No

Yes No

If you have ticked a shaded box 3 please give details below

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Yes No

Yes No

Section 8 – Goods In Transit

Own Vehicles

Own Vehicles

Sendings by Haulier, Rail and Post

Type of property carried

Reg. details

Make of vehicle

Type of body No. of trailers

Sum insured

per vehicle per trailer

£ £

£ £

£ £

£ £

1. Maximum number of vehicles used to carry goods at any one time

2. Are the vehicles used in conjunction with

Yes No a) market trading?

Yes No b) direct selling from vehicles?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

c) soliciting of orders?

d) commercial travelling?

3. a) Are any of your vehicles left loaded and unattended at night?

If the answer is ‘Yes’, what arrangements do you make for their garaging and safe custody?

b) Do you have permanent garage premises?

If ‘Yes’, what is the full address?

4. a) Are your vehicles fitted with

i) immobilising devices?

ii) any locks additional to those provided by the manufacturers?

iii) an alarm system?

b) If the answer to 4a), (i), (ii) or (iii) is ‘Yes’ please provide details

Postcode


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Yes No

Yes No

c) Are these devices put into operation whenever the vehicle(s) is (are) left unattended?

d) Is the alarm subject to a maintenance contract?

1. Estimated total value to be consigned in the year including incoming supplies and property consigned to you for which you are responsible

2. If any property is to be excluded, please give details

3. Limit any one package

4. Limit any one consignment

a) within Great Britain

b) to the Channel Isles, Isle of Man, Northern Ireland, Eire

c) on F.O.B. or F.O.A. terms

If ‘Yes’, by whom?

Yes

Yes

Yes

1. Commercial travellers samples in stockrooms, hotels or houses

2. Property on approval with customers

3. Property on demonstration

Yes4. Property at exhibitions

Yes5. Property at packers premises

Yes6. Property at outworkers premises

Optional Extensions

If you require cover please indicate 3 Further information may then be requested

Sendings by Haulier, Rail and Post

£

£

£

£

£

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Section 9 – Terrorism

Section 10 – Commercial Legal Expenses

Section 11 – Theft By Employees

Do you require this cover under

1. Material Damage and where operative the All Risks - Selected Articles Sections

2. Business Interruption and Accounts Receivable additionally

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Standard cover is based on a maximum limit any one claim of £50,000. Would you like us to consider a higher amount?

If yes what amount is required?

Standard Cover is based on a limit of £500,000 for all claims in the aggregate in any one period of insurance. Would you like us to consider a higher amount?

If yes what amount is required?

1. Has any insurer ever refused Commercial Legal Expenses insurance, imposed special terms or declined to renew a Commercial Legal Expenses Insurance Policy?

2. Has there been more than one dispute or legal proceeding to which this insurance would apply during the last three years?

3. Has there been ANY legal or tax dispute which has incurred costs in excess of £5,000?

4. Is there any enquiry, cause, event or circumstance which to your knowledge may give rise to a claim being made under this insurance?

1. How many people do you employ?

2. Do you obtain written references confirming the integrity of Employees?

For full details of the cover provided please refer to the Commercial Legal Expenses Section Summary of Cover.

£

£

5. Are there more than 10 properties and/or leases to which this insurance would apply?

If the answer to any of the above is YES, then please provide full details within the Additional Information Section.

General Questions

Please state

Limits of Indemnity required

Any One Employee or any one event

All claims in the Aggregate in any one Period

Yes No

3. Do you have a system whereby you or at least two employees check stock, money and all other business records at least monthly?

Yes No


£

£

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Section 12 – Engineering and Inspection Cover

Do you require any of the following Engineering covers?

Sudden and Unforseen Damage

Computer Cover

Machinery Movement

Contractors Plant and Equipment

Deterioration of Stock

Engineering Business Interruption

1. Basis of Cover

Which basis do you require cover on (please tick one)

a) Personal Accident Only

b) Personal Accident and Sickness

3. Operative Period of Cover (please tick one)

Occupational only

Occupational plus commuting

24 hour cover

Other basis (please specify in the Additional Information Section

Yes No

Yes No

Yes No

2. Insured Persons

Are all employees (including directors and partners) to be insured? Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Section 13 – Group Personal Accident and Sickness



If No please detail in the Additional Information Section the cover required

4. Please specify the basis of cover required (e.g.wages related, fixed benefits etc)

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Section 14 – Additional Information

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Signature of Proposer

(DD/MM/YYYY)

Date

No cover is in force until the Proposal has been accepted by AXA Insurance.

PART C – DeclarationIf you have not given full and true answers to all questions asked on this Proposal, your insurance cover may not protect you in the event of a claim.

If you wish to disclose something that has not been disclosed elsewhere on this Proposal, please use the box provided here.

Before signing the Declaration, please read the notices on this page about the Claims and Underwriting Exchange Register and Data Protection Act.

Name

Position in company

Claims and Underwriting Exchange RegisterInsurers pass information to the Claims and Underwriting Exchange Register run by Insurance Database Services Limited (IDS Ltd). The aim is to help us check information provided and also to prevent fraudulent claims. When we deal with your request for insurance we may search the register. When you tell us about an incident (such as fire, water damage or theft) which may or may not give rise to a claim, we will pass information relating to it to the register.

You can ask us for more information about this.

You should show this notice to anyone who has an interest in property insured under this policy.

DeclarationPlease read the Declaration carefully and then sign below. If there is more than one Proposer both should sign.

I/We declare that the answers given to questions asked in this Proposal are true and complete to the best of my/our knowledge and belief.

I/We understand that if I/we have not given full and true answers to all questions asked on this proposal that my/our insurance may not protect me/us in the event of a claim.

I/We understand that any material fact, which is information that may influence the Company in the acceptance of this insurance and the terms provided, has been disclosed and recorded.

I/We understand that you will pass the information on this form and about any incident I/we may give details of to IDS Ltd so that they can make it available to other insurers. I/We also understand that, in response to any searches you may make in connection with this application or any incident I/We have given details of, IDS Ltd may pass you information it has received from other insurers about other incidents involving anyone insured under the Policy.

I/We agree to accept the terms and conditions contained in the AXA Insurance UK plc Policy applying to this Proposal.

Data Protection NoticeAXA Insurance UK plc is a member of the AXA Group. To set up and administer your policy we will hold and use information including sensitive personal information (sensitive personal information may include such things as criminal convictions and health information) about you supplied by you. We may send it in confidence for processing to other companies in the AXA Group (or companies acting on our instructions) including those located outside the European Economic Area. By signing this form you consent to such use of your personal data including sensitive personal data.

AXA Insurance UK plc may send you details of our other products and services.

other AXA companies based within the European Economic Area

To enable them to send you details of their services, we may also share your name and address with:

other carefully selected companies outside the AXA Group.

You may be contacted in writing or by telephone or fax.

If you do not wish to receive such details, please tick the appropriate box(es).

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www.axa.co.uk

AXA Insurance UK plc Registered in England and Wales No 78950. Registered Office: 5 Old Broad Street, London EC2N 1AD. A member of the AXA Group of Companies. AXA Insurance UK plc is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Telephone calls may be monitored and recorded.

AXA is a world leader in wealth management and financial protection. We operate in over 50 countries and serve more than 50 million customers worldwide. We cater to a wide range of needs, providing advice and guidance to our individual and corporate customers on a variety of financial products and services. In addition to Business, Motor and Home Insurance we also offer Investments, Life Assurance, Retirement Planning, Long Term Care, Asset Management, Medical Insurance and Dental Payment Plans

With our expertise and commitment to customer service and consistent,

quality care, you can rely on aXa for lasting security.

ask abouT aXa’s eXCellenT range of business,

Home and moTor insuranCe ProduCTs

WC

B014

R/X

-B (0

4/15

) (37

8036

2)

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CommerCial Combined for Trade and indusTry - AXA … · CommerCial Combined for Trade and indusTry...

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