Business Interruption - Earnest Insurance

Postal Address Postcode

Premises postcode to be insured

If you are registered for VAT any claim for loss or damage to property will be paid exclusive of VAT, and you are advised to arrange your sums insured accordingly. Allowance should be made to include an amount for VAT in the sum insured if you are not registered.

1. Do you require a Quotation for:-
Employers Liability (not available on a stand alone basis)Public LiabilityProducts Liability (only available with public liability)

For Public and/or Products Liability, state limit of indemnity required. Please tick
$1,000,000$2,000,000$5,000,000$10,000,000<

2. Date Business commenced:

Are you a member of a trade association?
YesNo

If YES which?

Do you comply with the associations working code of practice?
YesNo

Do you have a standard contract between you and your client to which you comply?
YesNo
If YES please supply a copy

Proportion of your work undertaken based on this contract?

3. Do you have a written Health & Safety Policy?
YesNo
If YES please supply a copy

Do you have a designated person managing Health & Safety?
YesNo

If YES who?

Do you use an external Risk Management Consultant?
YesNo

If YES please provide supply name & address

Have you ever been prosecuted under the Health & Safety at Work Act or other statute or regulation?
YesNo

If YES please give details

4. Are your premises in good state of repair, and are your ways, plant and machinery (at your own premises and all contract sites) properly fenced and guarded and otherwise in good order and condition?
YesNo

5. Do you undertake design work for

a. your own contract
YesNo

b. other work
YesNo

6. Are all your employees contracts entered into in the United Arab Emirates?

YesNo
If YES please supply a copy

If no state number and nationality of foreign employees

8. Are you involved in any form of railway work?

Yes
No

9. Do you discharge any hazardous waste products (e.g. chemicals, gases, radioactive substances, dust, fumes or vapours) into the atmosphere, sewers, waterways or elsewhere?

Yes
No

If YES please advise type of waste and give full details of:

a. Storage and Disposal Methods

b. Treatment of Waste

c. Disposal Licences Held

d. Landfill Sites

10. Do you carry out any manual work away from your own premises including outside of the UAE?

Yes
No

If YES, please give details

11. Do you design, give advice or prepare specification?

Yes
No

If YES, please confirm separate Professional Indemnity cover

12. Do you supply any products that you do not manufacture?

Yes
No

If YES, do you

a. Retain rights of recovery against the manufacture
Yes
No

b. Alter, adapt or change any products?
Yes
No

If YES please give details including product, use, source of supply and type of alteration, adaptation or change. Give details of imported products including source and use.

13. Give details of any products used:-

a. In connection with aircraft or spacecraft (including ground control equipment)

b. In marine craft

c. Offshore

d. In nuclear installations

e. In safety critical parts for motor vehicles

14. Are any of your products, currently or any in the past 3 years supplied directly or to your knowledge indirectly to the USA or Canada ?

Yes
No

If YES, please give details

15. Are any of the goods known to be potentially harmful to health or require any hazard warning?

Yes
No

If YES, please give full details and attach particulars of safeguards, warnings, instructions for use and terms of sale

16. Do you have any representation outside of the UAE?

Yes
No

If YES, please give details and state territories involved

Description	Estimated Annual Payments
	Work at your premises		Away from your premises
	Current Est / Act	Next Year Est / Act	Current Est / Act	Next Year Est / Act
Clerical
All other Employees (Please specify what type i.e. roofers, scaffolders, etc)


Labour Gangers, Labour only sub-contractors & self employed sub-contractors supplying Labour only
Proposers own annual remuneration if working manually in the Business
Woodworking machinists / carpenters
Bona Fide Sub-Contractors (No EL cover)

Do you require contingent cover for Bona Fide Sub-Contractors?

TURNOVER
UAE
Rest of the World
USA/Canada Exports
Total Turnover

18. Have you had any claims made against you during the under noted period?

Yes
No

(If YES please give details)

Year	Total Wages	Deductible	Settled Claims		Reserves for Outstanding Claims
Employers Liability
Year	Total Wages	Deductible	No.	Amount	No.	Amount
1997
1998
1999
2000
2001
2002
2003
Total

Year	Total Wages	Deductible	Settled Claims		Reserves for Outstanding Claims
Public Liability / Products
Year	Total Wages	Deductible	No.	Amount	No.	Amount
1997
1998
1999
2000
2001
2002
2003
Total

19. Please state name of present and previous insurers over the last three years

Has the Insurer ever declined your proposal, refused to renew or cancelled your policy, increased your premium, or imposed special terms?
Yes
No

If YES please give details

ALL CONTRACTORS MUST COMPLETE ‘CONTRACTORS ADDITIONAL PAGE’
TO BE COMPLETED IN ALL CASES
IMPORTANT NOTICE

Failure to disclose material facts could result in your policy being invalidated. Material facts are those facts which might influence the acceptance or assessment of your proposal. If you are in any doubt as to whether a fact is material you should disclose it.

I/WE hereby declare that to the best of my/our knowledge all the statements given on this Proposal Form are true and complete and that I/we have disclosed all material facts that ought to be communicated to the Underwriters.

II/WE undertake to exercise all ordinary and reasonable precautions for the safety of the insured property.

I/WE hereby agree that this Proposal and this Declaration shall be the basis of the contract of the insurance between the Insurers and Myself/Ourselves.

Name

Position

Signature

Date

Law Applicable to Contract : If the proposer shown on this Proposal Form is a private individual or a sole trader then they are free to choose the law applicable to this Insurance Contract. This Contract will be subject to English Law (or Scottish Law where applicable)

Year	Nature	CONTRACT VALUE
CONTRACTORS ADDITIONAL PAGE

Commercial General Liability

Employers Liability

Public Liability / Products

CONTRACTORS ADDITIONAL PAGE

Do you undertake any work in connection with the following:-

Commercial General Liability

Employers Liability

Public Liability / Products

CONTRACTORS ADDITIONAL PAGE

Do you undertake any work in connection with the following:-

Submit