Additional Contractor Liability Proposal Form Page 4
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2
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4b)
After investigation, have there been any claims &/or uninsured losses, &/or circumstances
of which could give rise to a claim?
YES / NO
If “YES”, please complete the table below.
Date of Loss
Details of the claim/loss or
Is the claim
Incurred Loss
Excess
circumstance
Open or Closed
(i.e. Amount Paid
(incl. the cause, the
and Outstanding)
)
– circle one
activity, & when it was reported
___ / ___ / _____
Open or Closed $
$
___ / ___ / _____
Open or Closed $
$
___ / ___ / _____
Open or Closed $
$
6. PREVIOUS INSURANCE HISTORY OF THE PROPOSED CONTRACTOR/SUBCONTRACTOR
Have you ever had any:
a)
Insurance declined or cancelled?
YES / NO
b)
Renewal refused?
YES / NO
c)
Special conditions imposed on your insurance?
YES / NO
d)
Increased excess imposed on your insurance?
YES / NO
e)
Claims denied for this class of insurance?
YES / NO
f)
Criminal charges &/or convictions?
YES / NO
g)
Financial trouble resulting in an administrator being appointed &/or being declared bankrupt?
YES / NO
If “YES” to any of the above, please provide full details.
7. DECLARATION FROM THE PROPOSED CONTRACTOR/SUBCONTRACTOR
I/We
a)
declare that:
i.
I/we have read and understood the clauses detailed in the Important Notices section at the front of this Proposal;
ii.
the answers and information given by me/us in this Proposal are true and correct in all respects;
iii.
no information has been withheld that would affect the underwriter’s decision to accept this Proposal;
iv.
where answers in this Proposal are not in my/our own handwriting, they have been checked by me/us and I/we
agree they are correct;
b)
authorise the underwriters to give to, or obtain from other insurers or an insurance or credit reference bureau, any
information relating to these insurance covers, and any other insurances held by me/us and claims under those
insurances.
c)
understand that, if this Proposal is accepted, my/our insurance cover will be subject to the terms and conditions set
out in the Policy and not necessarily what I have elected on this Proposal.
d)
acknowledge that the underwriters and their agents reserve the right to decline this Proposal.
e)
acknowledge that the existing Insured controls the Liability Policy and remains the only party which can alter/vary
that Policy, and/or obtain information in regards to that policy.
Proposed Contractor/Subcontractors: Signature:
Name:
Title:
Date: _____ / _____ / _____
Prop PL Contractor-Subcontractor - 2013-08-01
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