• What you will need to complete this form:

  • Please have the following information available before you begin:

    • Details of any relevant membership or licence numbers
    • Annual turnover
    • Annual wageroll for employees and sub-contractors if applicable. 
    • Name of your current insurer
    • Current insurance policy expiry date
    • Details of any previous claims, including: date of claim, nature of claim, amount paid.

    Please note, we cannot quote if you are already insured via Hiscox.

  • Duty of disclosure of Material Facts (Duty of Presentation)

    A material fact is an important fact about you or your circumstances. Fair presentation means that you must have disclosed all material facts, matters and circumstances which you know, which could influence an insurer's or underwriter's decision to accept your insurance. This also applies to facts that you ought to know. You must disclose sufficient information to make the insurers aware that they need to make further enquiries. They can then choose to accept or decline your insurance. If they accept, they may apply certain terms. The duty of fair presentation is a significant obligation placed upon you under the contract of insurance. If you fail to meet this obligation, insurers can take various actions in accordance with the Insurance Act 2015.

  • Your details

  • Date of birth*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Is a joint policy required?*
  • Date of birth*
     / /
    2 digit day, 2 digit month, 4 digit year

  • Format: 00000 000000.
  • Have you or your business partners or directors ever had an insurance proposal declined, renewal refused or insurance cancelled or special terms applied?*
  • Have you or your business partners or directors ever been convicted of or charged (but not yet tried) or been given an official police caution in respect of any criminal offence, other than a minor motoring offence which are not spent under the Rehabilitation of Offenders Act?*
  • In the last 10 years, have you or your business partners or directors been declared bankrupt or insolvent or been the subject of bankruptcy proceedings or insolvency proceedings or been disqualified from being a company director?*
  • In the last 10 years, have you or your business partners or directors been ever been the subject of a County Court Judgement , an Individual Voluntary Arrangement, a Company Voluntary Arrangement or a Sheriff Court Decree?*
  • In the last 10 years, the business has not been subject to an investigation by HM Revenue and Customs which has resulted in a prosecution?*
  • Is your business owned by an individual or entity which appears on the financial sanctions list of the United Nations, the European Union, United Kingdom or United States of America or any of its states?*
  • Do you or your business partners or directors have any companies or business in any sanctioned territory?*
  • Do you or your business partners or directors export to or operate in any sanctioned territory or have any business dealings with individuals or entities that are known to be sanctioned under United Nations resolutions or the trade or economic sanctions laws or regulations of the European Union, United Kingdom or United States of America or any of its states?*
  • Do you or your business partners or directors have any involvement with any products or components associated with weaponry, arms or military goods?*
  • Have you or your business partners or directors had any claims, losses or incidents in the last three years?*

  • Your business details

  • Do you currently have insurance in place?*
  • If no, is this a new venture?*
  • Do you have a risk assessment in place for your business? Please note, (Cliverton do not need sight of these but in the event of a claim your insurers may ask for copies, it is a condition of the policy that these are in place)*
  • What date should your policy commence? (Please note we cannot back date cover)*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Please select all activities which apply to your business:*

  • Policy cover - Exclusions

    Please confirm you DO NOT undertake any of the following activities. If you answer yes to any of the below, we will need to refer to our underwriters to obtain cover for you. We may also ask for further information to assist the underwriters. 
  • Any door supervision of licensed premises or venues including pubs, clubs, hotels and ‘beer tents’?*
  • Any crowd control services such as pitch side stewarding or front of stage crowd control?*
  • Any public event event stewarding at events with an attendance of greater than 1000?*

  • Public Liability

    This section covers you for your legal liability including related legal costs, if someone is injured or their property is damaged as a result of your business activities, and where they can demonstrate that their loss is due to your negligence.

  • Please confirm you have not been:

  • Prosecuted by the Environment Agency and / or been subject to Civil Sanctions and / or been required to pay clean-up costs following a pollution incident?*
  • Prosecuted under Product Safety legislation?*
  • Forced to issue a product recall by the enforcing authorities?*

  • Compulsory sections:

  • What level of public liability cover do you require?*
  • Do you use any bonafide sub-contractors?*
  • If you engage the use of Bona Fide sub-contractors, do you check that they hold Public Liability Insurance, including efficacy cover, with a limit of indemnity of at least £1,000,000?*

  • Public Liability - optional extensions

    Please state if cover is required.
  • Do you require efficacy cover? This covers your failure perform the duties you have been contracted for.*
  • Do you require professional indemnity cover? This covers you for claims made against you for a breach of duty of care, or any negligent acts, errors or omissions.*
  • If you currently have professional indemnity cover in place, please confirm the date of commencement (retroactive date):
     - -
    2 digit day, 2 digit month, 4 digit year
  • Please state the level of cover required*
  • Do you require cover for cask carrying services?*
  • Do you require fidelity cover? This covers your legal liability for damages you may be liable to pay to any party arising solely as a result of any acts of fraud or dishonesty by any of your employees, up to a limit of £50,000.*
  • Have there been any incidents concerning damage to or theft of your customers property?*
  • Have there been any police investigations of any of your employees?*
  • Do you require financial loss cover? This covers your legal liability for financial loss incurred by others for claims made against you.*
  • Do you require cover for vehicle immobilisation services?*

  • Employers' Liability

    This section covers you for damages and costs which you are legally liable to pay in respect of bodily injury, for example, death, injury, illness, disease, mental injury and anguish, to an employee. You are legally obliged to arrange employers' liability insurance if you have paid employees and certain types of voluntary helpers.
  • Do you require employers' liability insurance?*
  • Do you have an ERN/PAYE reference number for your business?*

  • Your health and safety procedures:

  • Are all of your employees trained to the required Health and Safety standards and training records are kept up to date?*
  • Please confirm procedures are in place to fully train and supervise employees?*
  • Please confirm all equipment is tested and inspected inaccordance with current legislation?*
  • Please confirm risk assessments are carried out for all contracts, and method statements are provided to all employees?*

  • Personal accident section

    This section covers an injury sustained during the course or in connection with the described occupation, excluding any sickness or illness and injuries resulting from commuting to and from work.
  • Do you require cover for personal accident?*
  • Do you work off-shore?*
  • Do you pilot any aircraft?*
  • Do you work at depth and/or mining?*
  • Do you work as a diver?*
  • Do you work above height of 10 meters?*
  • Do you need personal accident cover for any employees?*

  • Goods in transit

    This section covers you for damage to property belonging to you or held in trust for which you are responsible while in transit anywhere within the UK.
  • Do you require cover for goods in transit?*

  • Business interruption

    This section covers you for a loss of income following an interruption or interference with the business resulting from damage to property used by you at the premises.
  • Do you require business interruption cover?*
  • Period of indemnity*

  • Property damage and theft

    This section covers buildings, contents, stock and tools belonging to you, for loss or damage at your home or business premises.
  • Do you require cover for property damage?*
  • Rows
  • Are the premises built solely of brick, stone or concrete and roofed solely of slate, tile, concrete or metal and maintained in a good state of repair?*
  • Have the premises suffered from or showing any signs of damage by subsidence, ground heave or landslip?*
  • Are the premises situated over made up ground or underground workings of any sort, or sited near a cliff?*
  • Are the premises occupied for the sole purpose of the business and otherwise only as private dwellings?*
  • Are the premises unfurnished, unused or unoccupied?*
  • Can the portions of the premises you occupy be seperately locked to prevent access?*
  • Are the premises located in an area with a history of flooding?*
  • Are the premises you occupy protected by adequate security devices and / or intruder alarm systems?*
  • Do any of your premises consist of flat roofed areas?*
  • Do you require cover for any contents?*
  • Rows
  • Do you require loss of use cover for your security dog? This is available for dogs up to the age of 6 years old and is subject to a vets report confirming they are healthy and fit for duty.*

  • Business all risks

    This section covers your specific property such as mobile phones, laptops and trailers against damage whilst away from your premises within Great Britain and Northern Ireland, including accidental damage cover. It can also provide cover for equipment hired in by you for your use, if it is lost, damaged or stolen whilst in your care.
  • Do you require business all risks cover?*
  • Rows
  • Do you require cover for vehicle immobilisation?*
  • Do you require cover for business money?*
  • Please provide your SIA licence expiry date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • How would you prefer to be contacted by Cliverton?*
  • Would you like to receive news and updates from Cliverton?*

  • Data Protection Act

    By accepting your insurance policy, you consent to us using the information we hold about you for the purposes of providing insurance and handling claims. This may involve processing sensitive personal data about you where it is necessary (for example health information or criminal convictions). This may mean we have to give some details to third parties involved in providing insurance cover. These may include insurance carriers, third party claims adjusters, fraud detection and prevention services, reinsurance companies and insurance regulatory authorities. Where such personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates. This consent must cover both the disclosure of such information to us and its use by us as set out above. The information provided will be treated in accordance with the UK Data Protection Act 2018. You have the right to apply for a copy of your information (for which we may charge a small fee) and to have any inaccuracies corrected.
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