Fillable Non-Negligence (6.5.1/21.2.1) Liability Insurance (JCT Insurance)

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Non-Negligence (6.5.1/21.2.1) Liability Insurance (JCT Insurance)

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  • 32 check-boxes
  • 71 other fields

Country of origin: UK
File type: PDF

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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: 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
Address of Property/Site undergoing Works
What is the Name, Position and Telephone Number of the person whom our Surveyor should contact if necessary?
What is the total value of the Works? This should include any
non-reclaimable VAT and Professional Fees
£
How much of the total Works value relates to:
Demolition
£
Groundworks e.g. excavation, piling, underpinning etc.
£
Substructure Construction e.g. basement installation
£
Superstructure Construction e.g. extensions
£
Other e.g. finishes, fittings, furnishing, landscaping etc.
£
Limit of Indemnity Required
£
Defects Liability Period Required
Under which Contract Conditions is the work to be carried out? E.g. JCT Intermediate 2016, Insurance Option C
Start
Completion
Please provide an overview of the Works being carried out at the premises
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: 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 planning permission was necessary, please advise the name of the council which has granted the permission and the planning
application number
2
Existing and Surrounding Buildings
Please provide details of the Property including but not limited to; construction, year of build, height, floor area and condition
Is any of the Property remaining occupied while the Works are carried out? If “Yes” please provide
details below, if “No” please advise when the building was last occupied and the type of occupation
Yes
No
Do the Works involve extensions which tie-in with any existing buildings? If “Yes” please give details
and method to be used
Yes
No
Please provide details of any work on columns, beams, slabs or load bearing walls requiring temporary propping or support
Description of all immediate surrounding property not forming part of the Works including but not limited to; construction, year
of build, current occupation and condition (if more than 4 addresses please provide details on a separate sheet)
Address 1
Address 2
Address 3
Address 4
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: 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
Has a Party Wall Award been completed with any of the above addresses? If “Yes” please note
insurers may request a copy
Yes
No
Have any Schedules of Condition been drawn up for the surrounding properties? If “Yes” please note
insurers may request a copy, if “No” please provide details why
Yes
No
3
Demolition
Please provide details of what is being demolished (if there is Demolition of internal walls state whether they are loadbearing and
if there is Demolition of external walls state how many storeys).
Minimum distance from nearest property
(where Demolition is not internal only)
Method of Demolition e.g. hand/hand held breakers –please also provide a copy of a method statement
Is there any Demolition below ground level? If “Yes” please advise:
Yes
No
Maximum depth below ground level
Minimum distance from nearest property
Will any shoring/propping be necessary? If “Yes” please provide details below
Yes
No
4
Groundworks
Please give a general description of the ground conditions
Is any Excavation to be undertaken? If “Yes” please give details below
Yes
No
Maximum depth of Excavation
Minimum distance from nearest property
Means of supporting Excavation
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: 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
Is any Piling to be undertaken? If “Yes” please give details and provide a copy of a method statement
Yes
No
Number of Piles
Maximum depth of Piles
Minimum distance from nearest property
Is any Underpinning to be undertaken? If “Yes” please give details and provide a copy of a method
statement
Yes
No
Overall length involved
Maximum depth
Maximum length any one bay
Minimum distance from nearest property
Is there any Ground Stabilisation to be undertaken? If “Yes” please give details below
Yes
No
Minimum distance from nearest property
Is there any Dewatering to be undertaken? If “Yes” please give details below
Yes
No
5
Please provide details of the Main Contractor undertaking Excavation/Underpinning/Piling/Ground Stabilisation/Dewatering
Name or Company Name
Established Date
Website
In respect of any covers to which this proposal relates, and any business in which you or any of your Directors, Partners or Officers
of the above companies are or have been engaged in:
Has any Insurer ever declined a proposal, refused renewal, terminated insurance or imposed special
terms in the last 5 years? If “Yes” please give details below
Yes
No
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: 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 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
Yes
No
Date of Occurrence
Brief Details of Claim (whether made or not)
Amount Paid/Reserve
Have any of your Directors, Partners or Officers ever been:
Declared bankrupt or subject to bankruptcy proceedings, had a company declared insolvent or gone
into liquidation?
Yes
No
Convicted or charged (but not yet tried) with any other criminal offence, other than a motoring
offence?
Yes
No
Prosecuted under any safety or environmental legislation during the last 5 years?
Yes
No
If “Yes” please provide details
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:
click to sign
signature
click to edit
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: 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
Additional Information:
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Non-Negligence (6.5.121.2.1) Liability Insurance (JCT Insurance)

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Completed 10 June 2021

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