Property and Casualty Insurance

SECTION 1: COMPANY DETAILS
Please state the name and address of the principal company for whom this insurance is required. Cover is also provided for the subsidiaries of the principal Company, but only if you include the data from all of these subsidiaries in your answers to all of the questions in this form:
Insured company:*
Address
Address Line 2 ZIP / Postal Code
Website
Contact Name:*
Email*
1.2 Please state when your company was established:*
1.3 Please state your income for the following years as set out in the box below:*
Domestic (Last complete financial year):*
Domestic (Estimate for current financial year):*
Domestic (Estimate for next financial year):*
The USA (Last complete financial year):*
The USA (Estimate for current financial year):*
The USA (Estimate for next financial year):*
Europe / Australia (Last complete financial year):*
Europe / Australia (Estimate for current financial year):*
Europe / Australia (Estimate for next financial year):*
Rest of the world (Last complete financial year):*
Rest of the world (Estimate for current financial year):*
Rest of the world (Estimate for next financial year):*
Total (Last complete financial year):*
Total (Estimate for current financial year):*
Total (Estimate for next financial year):*
1.4 Please state the number of employees:*
1.5 Please state the following:
a) Your total estimated payroll for the next financial year:*
b) The percentage of your payroll that relates to work away from your premises (In %):*
c) The percentage of manual work (In %):*
SECTION 2: ACTIVITIES
2.1 Please briefly describe below the nature of your business activities. If you have a brochure, or company literature, please attach to this form.*
2.2 Please provide a full breakdown of your total revenue by activity. The total of all activities listed here should equal 100%.*
Activity (In %)
2.3 Do you own any premises in the US other than a sales office?*
- Yes
- No
If ‘yes’, please provide details:*
SECTION 3: CONTRACT INFORMATION
3.1 Please provide details of your three largest contracts:*
Contract Contract value Territory
a) the maximum height you will be working at (In Meter):*
b) the maximum depth you will be working to (In Meter):*
c) whether you perform heat work away from your premises?*
- Yes
- No
3.3 Do you employ bona-fide sub contractors (BFSC)?*
- Yes
- No
a) What approximate percentage of your income, in your current financial year, will be paid to BFSC (In %):*
b) Whether you sign reciprocal hold harmless agreements?*
- Yes
- No
c) Whether you ensure that BFSC have their own commercial general liability insurance?*
- Yes
- No
If yes, what is the minimum limit of liability that BFSC must purchase?*
SECTION 4: PRODUCT INFORMATION
Please only complete this section if you have any products sales
4.1 Please state your annual income for your three largest products in the following territories:*
Product description Domestic The USA Europe / Australia Rest of the world
4.2 Do you import products from territories outside of the USA, Australia or Europe?*
- Yes
- No
a) The territories from where you import these products and the precentage of sales income:*
Territory % sales income
b) Whether you maintain full rights of recourse against suppliers:*
- Yes
- No
c) Whether you ensure that your suppliers have their own products liability insurance?*
- Yes
- No
If yes, what is the minimum limit of liability that your supplier must purchase?*
4.3 Are any of your products incorporated into marine craft, aircraft, aerospace craft, nuclear devices, nuclear systems or automobiles?*
- Yes
- No
if ‘yes’, please provide details:*
SECTION 5: PREMISES DETAILS
5.1 Please provide below details of your premises:
Address
Address Line 2 ZIP / Postal Code Country
a) the purpose of the premises (e.g. office, warehouse, etc.):*
b. i) when approximately the premises was built :*
b. ii) when approximately the premises was last renovated:*
c) how the premises is constructed:
- Brick veneer
- EIFS
- Fire resistive
- Frame
- Heavy timber
- Joisted masonry
- Masonry non-combustible
- Non-combustible
- Semi-fire resistive
- Stucco
d) when approximately the roof of the premises was last renovated:*
e) how the roof of the premises is constructed:
- Concrete / Clay tiles
- Membrane
- Metal sheathing
- Shingles
- Wind resistive shingles
- Wood shakes
- Other
If other please explain :*
f) the class rating issued by the Public Protection Classification (PPCTM) program for the premises (1-10):*
Address
Address Line 2 ZIP / Postal Code Country
a) the purpose of the premises (e.g. office, warehouse, etc.):*
b. i) when approximately the premises was built :*
b. ii) when approximately the premises was last renovated:*
c) how the premises is constructed:
- Brick veneer
- EIFS
- Fire resistive
- Frame
- Heavy timber
- Joisted masonry
- Masonry non-combustible
- Non-combustible
- Semi-fire resistive
- Stucco
d) when approximately the roof of the premises was last renovated:*
e) how the roof of the premises is constructed:
- Concrete / Clay tiles
- Membrane
- Metal sheathing
- Shingles
- Wind resistive shingles
- Wood shakes
- Other
If other please explain :*
f) the class rating issued by the Public Protection Classification (PPCTM) program for the premises (1-10):*
5.1 Please state whether the premises:
a) is detached:*
- Yes
- No
If no, please state what measures are in place to protect the premises from damage if there is a fire in a neighboring property:
b) is self contained with a lockable entrance door:*
- Yes
- No
If yes, please state the type of locking system:
- Key operated multi-point locking system with at least 3 locking bolts:
- Rim automatic deadlock:
- Mortice deadlock:
c) contain other external doors:*
- Yes
- No
If yes, please state the type of locking system:
- A key operated security bolt:
- A panic bar locking system:
d) has lockable opening windows on all levels:*
- Yes
- No
If yes, please state the type of locking system:
- Secured by a key operated locking device:
- N/A (i.e. permanently sealed shut):
e) is protected by fire and central station intruder alarm systems which are connected to all windows and doors and is subject to an annual maintenance contract:*
- Yes
- No
f) is protected by interior and exterior cameras:*
- Yes
- No
g) is overseen by 24 hour security guards:*
- Yes
- No
NOTE: We may refuse to pay a claim if all of the devices for the security of your premises (including locks and the intruder alarm) are not in full and effective operation whenever the premises are closed for business or otherwise left unattended.
h) is free from cracks or other signs of damage that may be due to subsidence, landslip or heave and have not previously suffered damage by any of these causes:*
- Yes
- No
i) is in an area free from flooding and not near the vicinity of any rivers, streams or tidal waters:*
- Yes
- No
j) is self contained with a lockable entrance door:*
- Yes
- No
k) is heated by one of the following methods: conventional electric, gas, oil or solid fuel heating system:*
- Yes
- No
l) is fitted with electrical installations which are inspected at least every 5 years by a qualified electrician and any defect remedied:*
- Yes
- No
m) has lifts, boilers, steam and pressure vessels inspected and approved to comply with all of the statutory requirements:*
- Yes
- No
n) is fitted with sprinklers throughout:*
- Yes
- No
o) has a back up system for the electrical supply:*
- Yes
- No
NOTE: Assuming you have answered ‘yes’ to questions l) and m) above, it is important to keep records of all relevant inspections as we may ask for evidence of these before paying a claim.
If you have answered ‘no’ to any of the above questions then please give further details:
5.3 Do any of the listed premises contain composite or sandwich panels?*
- Yes
- No
If yes, please provide details:
5.4 Do any of the listed premises contain aluminium wiring?*
- Yes
- No
If yes, please provide details:
5.5 Do you maintain written and electronic records of all stock?*
- Yes
- No
If no, please explain why:
5.6 i) Would you like a quotation for either of the following extensions? (Earthquake) :*
- Yes
- No
5.6 ii) Would you like a quotation for either of the following extensions? (Flood) :*
- Yes
- No
SECTION 6:
INSURANCE REQUIREMENTS AND CLAIMS HISTORY
NOTE: The amounts insured you state below should be the full rebuilding or replacement cost in each of the categories. If you understate these amounts you will be under-insuring and we may not pay the full amount of your claim. It is therefore essential that these amounts are as close to the true values of the insured items as possible.
Building coverage (PREMISES 1):*
Building coverage (PREMISES 2):*
Loss of income (PREMISES 1):*
Loss of income (PREMISES 2):*
Indemnity period (PREMISES 1):*
Indemnity period (PREMISES 2):*
Loss of rent (PREMISES 1):*
Loss of rent (PREMISES 2):*
Indemnity period (PREMISES 1):*
Indemnity period (PREMISES 2):*
Inventory / stock (PREMISES 1):*
Inventory / stock (PREMISES 2):*
Cultivation equipment (PREMISES 1):*
Cultivation equipment (PREMISES 2):*
Business personal property (PREMISES 1):*
Business personal property (PREMISES 2):*
Tenants improvements (PREMISES 1):*
Tenants improvements (PREMISES 2):*
6.2 Please provide details of your current commercial general liability insurance, if applicable, and what you require for the next year of insurance:
6.2 i) Please provide details of your current commercial general liability insurance, if applicable, and what you require for the next year of insurance:*
Effective date (Current)(MM/YY): Limit (Current): Deductible (Current): Premium (Current): Insurer (Current):
6.2 ii) Please provide details of your current commercial general liability insurance, if applicable, and what you require for the next year of insurance:*
Effective date (Required) (MM/YY): Limit (Required): Deductible (Required):
6.3 Regarding all of the types of insurance to which this application form relates, AFTER INQUIRY:
a) have you ever had a legal action brought against you for causing property damage or bodily injury to a third party?*
- Yes
- No
b) are you aware of any circumstances which may give rise to a legal action being brought against you for causing property damage or bodily injury to a third party?*
- Yes
- No
c) have you ever incurred any loss as a result of damage occurring to any of the premises to be insured or have any of the premises to be insured incurred any damage?*
- Yes
- No
If the answer to any of the above is ‘yes’, then please attach full details including an explanation of the background of events, the maximum amount involved / claimed, the status of the claim(s) or circumstance(s) and any reserve(s) or payment(s) made by you and / or by Insurers, and the dates of all developments and payments.
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SECTION 7: DECLARATION*
I agree to the privacy policy.
• I declare that after proper enquiry the statements and particulars given above are true and that I have not mis-stated or suppressed any material fact.
• I agree that this application form, together with any other material information supplied by me shall form the basis of any contract of insurance agreed upon.
• I undertake to inform Underwriters of any material alteration to these facts occurring before the completion of the contract.
Name:*
Position held:*
Date*
DD slash MM slash YYYY
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Activity	(In %)

Contract	Contract value	Territory

Product description	Domestic	The USA	Europe / Australia	Rest of the world

Territory	% sales income

Property and Casualty Insurance

SECTION 1: COMPANY DETAILS

SECTION 2: ACTIVITIES

SECTION 3: CONTRACT INFORMATION

SECTION 4: PRODUCT INFORMATION

SECTION 5: PREMISES DETAILS

SECTION 6: