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 you are attending:
Please state the name, address and type of venue?:
Is your stand indoors, outdoors or in a temporary structure:
When does your event start (date)?:
-
Month
-
Day
Year
Date
When does your event finish (date)?:
-
Month
-
Day
Year
Date
When will you begin setting up your event at the venue (date)?:
-
Month
-
Day
Year
Date
When will you complete breaking down your stand and leave the venue (date)?:
-
Month
-
Day
Year
Date
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Liability Insurance
Please state the required value for Public Liability Insurance (or values for multiple quotes):
What is the expected attendance per day at the entire event?:
What will the expected attendance per day be at your stand?:
Please state the size of your stand (meters square):
Will your stand be a shell scheme, space with pop up displays or space with custombuild?:
Will you ensure that the erectors of any structures on your stand are made responsible for Public Liability insurance and that such insurance has a sum insured at least equal to that requested herein and will you check to ensure that such insurance is current?
Yes
No
Will alcohol be on sale or available on your stand?
Yes
No
Will there be any celebrities present on your stand?
Yes
No
Will any of the following be present at your event: Motorised/Mobile/Water Bound Activities, Arial Displays or Processions, Fireworks or Explosives, Stunts/Racing or any kind of hazardous activity?:
Yes
No
If Yes please provide details:
Will suitably qualified staff be in attendance to provide First Aid?:
Yes
No
Do you require Employers Liability?:
Yes
No
If yes please state the activities being undertaken by employees (including casual staff and volunteers):
Please confirm the number of employees including volunteers:
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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):
Have you obtained all applicable visa, licences or permits that may be required?:
Yes
No
Have you signed your contract with the organiser?:
Yes
No
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Final Confirmation
I declare that I have never been
1. Bankrupt
2. Disqualified from being a Company Director
3. Involved as an owner, director, or partner with any company that went into receivership, administration, or liquidation
4. Convicted (or charged but not tried) of any criminal offence involving dishonesty of any kind
5. Organising or attending an event where you have suffered a loss :
Yes
No
If you have selected NO please give details:
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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:
Submit
Should be Empty: