Property
& casualty
Application form
United Kingdom
CFC Property and Casualty UK v1.0
CFC Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©2018 CFC Underwriting Ltd, All Rights Reserved
1
INTRODUCTION
The purpose of this application form is for us to find out more about you. Completion of this application form does not oblige either you or
us to enter into a contract of insurance.
Following a reasonable search you must provide us with all information which may be material to the cover we offer in a clear and accessible
manner. Information is material if it would influence our decision whether to insure you, what cover we offer you or what premium we charge
you. If you are in any doubt whether a fact or circumstance is material you should disclose it.
HOW TO COMPLETE THIS FORM
Whoever fills out the form must be a principal, officer, director or partner of the applicant company. They should make all the necessary
enquiries of their fellow senior management, employees and persons responsible for arranging the insurance to enable our questions to be
answered.
If you require extra space to answer the questions or provide any other material information, please use the additional information section at
the back of the form. Once you have completed the form please return it directly to your insurance broker.
SECTION 1: COMPANY DETAILS
1.1 Please provide the following details:
Company:
Address:
Postcode:
Website:
Please state when your company was established:
Please state your income for the following years as set out below:
Territory
Last complete financial year
Estimate for next financial year
UK:
£
£
£
USA:
£
£
£
Rest of world:
£
£
Total:
£
£
£
Please state the number of employees:
Please state the wage rolls for the following:
a) clerical:
b) manual work:
c) work away (including heat work):
d) wood work:
£
£
£
£
CFC Property and Casualty UK v1.0
CFC Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©2018 CFC Underwriting Ltd, All Rights Reserved
2
e) LOSC:
Please state your Employer’s Reference Number (ERN)/ Employer PAYE reference:
Please state:
a) the maximum height you will be working at:
b) the minimum height you will be working at:
c) whether you perform heat work away from your premises?:
Yes
No
1.8 Do you employ bona-fide sub-contractors (BFSC)?:
Yes
No
if yes, please state:
a) what approximate percentage of your income, in your current financial year,
will be paid to the BFSC:
b) whether you sign reciprocal hold harmless agreements?:
Yes
No
c) whether you ensure that BFSC have their own commercial general liability insurance?:
Yes
No
SECTION 2: ACTIVITIES
2.1 Please describe below the products and services supplied by your business:
2.2 Please provide an approximate breakdown of how your revenue is generated from your products and services:
2.3 Please state whether you own any premises in the US other than a sales office:
Yes
No
If yes, please provide full details:
%
£
m
m
CFC Property and Casualty UK v1.0
CFC Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©2018 CFC Underwriting Ltd, All Rights Reserved
3
SECTION 3: PRODUCT INFORMATION
3.1 Please complete the following in respect of your three largest projects in the past three years:
Name of client Annual contract income Duration
3.2 Do you import products from territories outside of the USA, Australia or Europe?
Yes
No
If ‘yes’, please state:
a) the territories from where you import these products and the percentage of sales income:
Territory
% generated from the sales of these imported goods
b)
whether you maintain full rights of recourse against your suppliers:
Yes
No
c)
whether you ensure that your suppliers have their own products liability insurance:
Yes
No
If 'yes, what is the minimum limit of liability that your supplier must purchase?
3.3 Please state whether any of your products are incorporated into marine craft, aircraft, aerospace craft,
Yes
No
nuclear devices, nuclear systems or automobiles:
If ‘yes’, please provide details:
3.4 Please state whether your products:
a)
meet all applicable product safety standards in the territories where they are sold:
Please attach a sample copy of your product safety standard certificates.
No
N/A
Yes
No
b)
are labelled with all applicable product safety warnings:
Yes
No
c)
are supplied with clear instructions for their use:
Yes
No
3.5 Please state whether you have a written emergency product recall in place:
If ‘yes’, please provide a copy.
Yes
No
%
%
%
Nature of work
CFC Property and Casualty UK v1.0
CFC Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©2018 CFC Underwriting Ltd, All Rights Reserved
4
SECTION 4: PREMISES DETAILS
4.1 Please state:
a) the purpose of the premises (e.g. office, warehouse, etc.):
b) when approximately the premises was:
i. built:
ii. last renovated:
c) whether the premises is self-contained with its own means of access:
Yes
No
d) how the premises is constructed:
Steel frame Brick/Concrete/Stone Steel sheet Other:
e) when approximately the roof of the premises was last renovated:
f) how the roof is constructed:
Pitched tiled Slate Profile steel sheeting Other:
g) the percentage of flat roof on the premises:
h) how the floor is constructed:
Concrete Timber Other:
d) whether composite panels are used in construction:
Yes
No
If yes, please state:
the age of composite panels:
whether the panels are LPC approved:
Yes
No
the type of infill:
4.2 Please state whether the premises:
a) is detached:
Yes
No
If no, please state what measures are in place to protect the premises from damage if there is a fire in a neighbouring property:
b) is self-contained with a lockable entrance door:
Yes
No
If no, please provide details on alternative security:
c) is protected by:
Security grills Shutters Window bars
%
CFC Property and Casualty UK v1.0
CFC Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©2018 CFC Underwriting Ltd, All Rights Reserved
5
d) contains other external doors:
Yes
No
If yes, please state the type of locking system:
Key operated security bolt Panic bar locking system Other:
e) has lockable opening windows on all levels:
No
If yes, please state the type of locking system:
Key operated locking device: N/A (i.e. permanently sealed shut):
f) is protected by intruder alarm systems which are connected to all windows and doors and is
subject to an annual maintenance contract:
Yes
No
If yes, please state the type of alarm:
Bells only Central station DigiCom RedCare
g) is protected by intruder alarm systems which are connected to all windows and doors and is
subject to an annual maintenance contract:
Yes
No
h) is protected by exterior and interior cameras:
Yes
No
i) is overseen by 24 hour guards:
Yes
No
NOTE: we may refuse to pay a claim if all of the devices for the security of your premises including locks and the intruder alarm are not
in full and effective operation whenever the premises are closed for business or otherwise left unattended.
j) is free from cracks or other sign of damage that may be due to subsidence, landslip or heave
and have not previously suffered damage by any of these causes:
Yes
No
k) is in an area free from flooding and not near the vicinity of any rivers, streams or tidal waters:
Yes
No
l) is heated by one of the following methods: conventional electric, gas , oil or solid fuel heating:
Yes
No
m) has lifts, boilers, steam and pressure vessels inspected and approved to comply with all of the
statutory requirements:
Yes
No
n) has a back-up system for the electrical supply:
Yes
No
o) has any portable premises:
Yes
No
NOTE: assuming you have answered ‘yes’ to the questions l) and m) above, it is important to keep records of all the relevant inspections
as we may ask for evidence of these before paying a claim.
If you have answered ‘
no’
to any of the above questions then give further details:
4.3 Are any of the premises listed?
Yes
No
If ‘yes’, please state the grade:
Grade I Grade II
4.4 If applicable, how is your stock stored at your premises?
Yes
CFC Property and Casualty UK v1.0
CFC Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©2018 CFC Underwriting Ltd, All Rights Reserved
6
4.5 Are flammable/hazardous kept in a specialist, flame proof cabinet in line with health and safety
regulations?
Yes
No
If ‘yes’, please provide details:
4.6 If requesting a limit for Business Interruption, do you have a business continuity plan in place?
Yes
No
If ‘yes’, please provide details:
5.1 Please provide details of your current insurance:
Current insurer:
Limit:
Public/Products liability:
Employers’ liability
5.2 Please provide details of the amounts to be insured for your premises:
NOTE: In respect of commercial property, the amounts insured you state below should be the full rebuilding or replacement cost in each
of the categories. If you understate these amounts you will be under-insuring and we may not pay the full amount of your claim. It is
therefore essential that these amounts are as close to the true values of the insured items as possible.
Declared value:
Amount insured:
Building:
Landlords fixtures & fittings:
Fixed computers:
Other office contents:
Stock
Portable computers:
Other portable equipment:
Gross revenue/ Gross profit:
Increased cost of working
Additional increased cost of
working:
Indemnity period
months
SECTION 5: INSURANCE REQUIREMENTS
CFC Property and Casualty UK v1.0
CFC Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©2018 CFC Underwriting Ltd, All Rights Reserved
7
SECTION 6: CLAIMS EXPERIENCE AND INSURANCE HISTORY
AFTER FULL ENQUIRY:
a) are you aware of any circumstances which may give rise to a claim under this policy, or
b) has any principal, partner, director or officer of the companies to be insured, or the companies themselves, been found guilty
of any criminal, dishonest or fraudulent activity or been investigated by any regulatory body, or
c) are you aware of any loss or damage, whether insured or not, that has occurred to any of the companies to be insured within
the last 5 years?
With reference to questions a), b) and c) above:
Yes
No
If the answer to the above is yes then please attach full details including an explanation of the background of events, the
maximum amount involved or claimed, the status of the claims or circumstances and any reserves or payments made by you or
by insurers, and the dates of all developments and payments.
SECTION 7: DECLARATIONS
I declare that:
after full enquiry the answers to the questions contained in this application form, and any other information supplied by me,
are substantially true, accurate and correct;
I will inform underwriters before cover incepts of any change to the information supplied by me; and
I understand that if any of the information contained in this application form or provided elsewhere is substantially untrue,
inaccurate or incorrect, or I have not disclosed any other information that is material, the Policy may be avoided without any
return of premium, the terms and conditions may change, a higher premium may become payable or we may reduce the
amount of any claim payment.
Signed:
Full name:
Position held:
Date:
DD / MM / YY
5.3 When would you like your insurance to start?
DD / MM / YY
click to sign
signature
click to edit
CFC Property and Casualty UK v1.0
CFC Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©2018 CFC Underwriting Ltd, All Rights Reserved
8
ADDITIONAL INFORMATION:
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