Public Liability Insurance Proposal

Purpose built? YesNo
Purpose built? YesNo
Purpose built? YesNo
Tenure SingleMulti
Tenure SingleMulti
Tenure SingleMulti
If you are the owner or lessee, are you aware of the use to which the land/premises was put prior to your occupation?
YesNo
YesNo

YesNo
YesNo
YesNo
YesNo
YesNo
If yes please provide the following information
- Details of the work subcontracted and estimated payments for the next 12 months
YesNo
YesNo
If yes please provide details
YesNo
If yes please provide details
YesNo
If yes please provide details

CLAIMS AND RELATED DETAILS
Have any incidents occured during the last 5 years resulting in injury (including death, disease or illness) to members of the public or damage to their property arising out of:-

YesNo
YesNo
YesNo
If yes please provide details
YesNo


Public Liability:

Products Liability:

YesNo
YesNo
YesNo
YesNo
IMPORTANT


The questions on this form and any other details the Company may request in connection with the Proposal for insurance relate to facts which the Company considers material to underwriting this insurance, however because no list of questions can be exhaustive please consider if there is any other material information relevant to this proposal, which could influence the company assessment and acceptance of the insurance, and advise the company accordingly. Failure to disclose all material facts whether or not the subject of a specific question may invalidate the insurance.



DECLARATION


I/We warrant that the above statements made by me/us or on my/our behalf are true and complete and i/we agree that this proposal shall be the basis of the contract between me/us and the Company. I/We agree to accept a policy in the company's usual form for this class of insurance.



NOTE: Signing this form does not oblige you to complete the insurance.)