Fillable Land Owners Liability Proposal Form (JCT Insurance)

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Land Owners Liability Proposal Form (JCT Insurance)

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The Land Owners Liability Proposal Form (JCT Insurance) form is 2 pages long and contains:

  • 1 signature
  • 23 check-boxes
  • 14 other fields

Country of origin: UK
File type: PDF

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Land Owners Liability Proposal Form
Proposal Form for Land Owners Liability
Please return completed form to:-
Expert Insurance Group Horsted Square Bellbrook Business Park Uckfield Sussex TN22 1QG or Fax 01825 761479
w: www.jctinsurance.com t: 01825 745 410 e: enquiries@jctinsurance.com
Expert Insurance Group is a trading style of Affinity Select Insurance Services Limited
Authorised & regulated by the Financial Services Authority Registered in England No 3565404
Please complete in CAPITAL LETTERS using black ink and tick boxes as appropriate. Please complete all questions where applicable and
provide full details where applicable, particularly for questions with GREY boxes.
1
Employer Details
Name or Company Name
Email Address
Telephone Number
Correspondence Address
Made an insurance claim on this type of insurance (whether paid or not) in the last 5 years?
Yes
No
Ever been convicted of any criminal offence, other than a motoring offence?
Yes
No
Ever been declared bankrupt or subject to bankruptcy proceedings?
Yes
No
Ever had this type of insurance declined, cancelled or any special terms imposed for any reason?
Yes
No
Address of Land
What is the size of the land to be insured, in acres?
What is the land used/going to be used for? E.g. development site, grazing, moorland, woodland, private road etc.
Is the land being used to grow crops for a commercial benefit?
Yes
No
Do you allow neighbours to use the land to let their animals graze?
Yes
No
Are there any buildings/structures on the land?
Yes
No
Are there any watercourses or significant water features within the land to be insured or adjacent?
Yes
No
Are there any footpaths or rights of way attaching to, over, or adjacent to the land to be insured?
Yes
No
Is or was the land ever used by any Petrol Station, Chemical Works, Gas Works, Oil Refineries, Power
Stations, Underground Mines or any other industries of this nature?
Yes
No
Land Owners Liability Proposal Form
Proposal Form for Land Owners Liability
Please return completed form to:-
Expert Insurance Group Horsted Square Bellbrook Business Park Uckfield Sussex TN22 1QG or Fax 01825 761479
w: www.jctinsurance.com t: 01825 745 410 e: enquiries@jctinsurance.com
Expert Insurance Group is a trading style of Affinity Select Insurance Services Limited
Authorised & regulated by the Financial Services Authority Registered in England No 3565404
If you have answered “Yes” to any of the above questions, please provide details below
What limit of liability is required?
£1,000,000
£2,000,000
£5,000,000
IMPORTANT
Please read the following carefully before you sign and date the Declaration.
If you have answered “Yes” to any of the questions on this enquiry form with a GREY BOX, please supply any Additional Information
unable to be included in the space provided on the next page.
The questions on this proposal form and any other details we specifically request relate to facts which we consider material to
underwriting this insurance. However, because no list of questions can be exhaustive please consider whether there is any other
material information which is known to you which could influence our assessment and acceptance of the risk. Failure to disclose all
material facts whether or not the subject of a specific question may invalidate your insurance.
We recommend that you should keep a record, including copies of letters and this Proposal Form, of all information supplied to us for
the purpose of entering into this insurance.
DECLARATION
Before signing the Declaration please check your answers carefully, particularly if this Proposal Form is not completed in your own hand
I/We declare that to the best of my/our knowledge and belief the answers given are true and complete.
I/We agree that if any answers have been completed by any other person, such person shall for that purpose be regarded as my/our
agent and acting on my/our behalf.
I/We agree that the information provided on this Proposal Form and any information supplied by me/us shall be incorporated in and
form part of the insurance contract.
Signature of Proposer(s)
Date of signing
Title of Signatory:
Additional Information
Please Note: A text based signature is not accepted by insurers
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Land Owners Liability Proposal Form (JCT Insurance)

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Completed 10 June 2021

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