Fireworks Display Insurance Proposal

General Information
Are you an Insurance Broker or Direct Client:
Insurance Broker Company Name:
Financial Services Authority Number:
Insured Company Name (or Insured Person):
Contact Name:
Telephone: *
Email: *
example@example.com
Please provide a description of the event:
Has the event been held before?:

Yes No
If yes how many times?:
Has the event ever suffered a loss of any kind?:

Yes No
If yes please provide details:
Please state the name, address and type of venue:
When does your event start (date)?:

Day Month Year
Date
When does your event finish (date)?:

Day Month Year
Date
When will you begin setting up your event at the venue (date)?:

Day Month Year
Date
When will you complete breaking down your stand and leave the venue (date)?:

Day Month Year
Date

Cancellation Insurance
Do you require Cancellation Insurance?:

Yes No
On which basis do you wish to insure? You may request a quotation for both options?:

Costs, expenses & commitments Loss of revenue (ie. totalincome including profits)
Costs, expenses &commitments:
Loss of revenue (ie. total income including profits):

Declaration
Important Notice
Please note that failure to disclose all material facts (that is those facts an insurer would likely to influence the acceptance or assessment of this proposal) may invalidate the Insurance. If you are in any doubt whether a fact is material you should disclose it. You are advised to keep a record (including copies of letters) of all information supplied to the Insurer for the purpose of entering into the contract of insurance. A copy of the completed proposal form is available on request for a period of 3 months after it’s completion.
Declaration
I / We declare that the particulars and statements given in this Proposal and the information provided are to the best of my/our knowledge and belief complete and true, and I am / We are willing to accept the Certificate of Insurance issued by Worldwide Hole ’N One Ltd on behalf of certain Lloyd’s Underwriters including its terms, conditions, and exclusions.
Name:

First Name Last Name
Position:
Should be Empty:

General Information