Non-Negligence (6.5.1/21.2.1) Liability Insurance
Proposal Form for Non-Negligence
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: firstname.lastname@example.org
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 Note: A text based signature is not accepted by insurers
Have any accidents, losses or claims arisen, whether insured or not, in the last 5 years? If “Yes” please
complete the following table
Brief Details of Claim (whether made or not)
Have any of your Directors, Partners or Officers ever been:
Declared bankrupt or subject to bankruptcy proceedings, had a company declared insolvent or gone
Convicted or charged (but not yet tried) with any other criminal offence, other than a motoring
Prosecuted under any safety or environmental legislation during the last 5 years?
If “Yes” please provide details
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.
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.
click to sign
click to edit