ࡱ> q` #bjbjqPqP 5::q  $$$8$% Nh&(:(((*&** xGzGzGzGAG J M$bPhRM /**//M ((N.222/ ( (xG2/xG22A| T TC(& fHS$X0XB,ELN<NjBXS0rXS$TCXS TC*+2U,|,***MMX2^***N////      NEIGHBOURHOOD WATCH SPECIAL EVENTS INSURANCE STATEMENT OF FACTS IT IS VERY IMPORTANT THAT YOU CAREFULLY READ ALL OF THIS STATEMENT Arranged by: Keegan & Pennykid (Insurance Brokers) Limited, 50 Queen Street, Edinburgh, Midlothian, EH2 3NS Tel: 0131 225 6005 Fax: 0131 226 3811  HYPERLINK "http://www.keegan-pennykid.com" www.keegan-pennykid.com E-mail: mail@keegan-pennykid.com Agent Reference:  FORMTEXT       Some words in this Statement of Facts are in italics and have a particular meaning which are stated below:AgentKeegan & Pennykid (Insurance Brokers) LimitedMaterial fact(s)is a fact that might influence our assessment or acceptance of your application for insuranceWe/us/ourAnsvar Insurance Company Limited.You/yourthe Neighbourhood Watch Association Scheme or individual(s) named as organisers of the EventAbout this Statement: This Statement is a record of the information that you, or your agent, has given to us as your proposal for this insurance and it: contains all the material facts for the required insurance; has been used by us to assess the risk in order to provide you with a quotation for insurance cover; is the basis of the contract between you and us. Failure to disclose a material fact may result in the insurance being inoperative. It is your legal duty to disclose all material facts when applying for insurance. If you are in any doubt as to whether or not a material fact should be disclosed please refer to your agent. You should check the information shown in this Statement to ensure that everything is correctly stated. Please tell your agent within 7 days if anything needs to be changed and they will advise you if the change(s) affect the acceptability of the insurance. In addition to this Statement please keep a record of all other information supplied to your agent for your proposal. This Statement on its own is not confirmation or evidence of cover.About the policy: A Key Facts summary of cover is attached. A copy of the standard policy wording is available on request to your agent. The Law of the territorial limits (defined in the policy wording) relating to your contact address will apply to this insurance. English Law will apply in the event of any dispute over the applicable Law. Statements about you in connection with this insurance: Your Neighbourhood Watch registration with the police authorities is currently effective. You have not made any claim or incurred any liability, for any of the risks proposed, in the past 3 years Your event is being held solely for the benefit of Neighbourhood Watch Your Event is one, or more, from the following list only: Barbecues; Bazaars; Bingo; Car boot sales; Card games (e.g.bridge); Charity auctions; Coffee mornings; Concerts (excluding rock concerts); Conferences; Craft fairs; Dances (excluding discos); Dinners; Exhibitions; Fetes; Film shows; Flower shows; Fun days; Garden parties; Jumble sales; Outings/excursions; Quiz evenings; Raffles; Seminars; Sponsored walks; Sports days (non-contact sports only), Themed parties; Treasure hunts (excluding motorised vehicles). Your Event does not include any of the following activities: Abseiling; Activity-type inflatables (except bouncy castles); Aerial runways; Any use of motorised vehicles; Archery; Assault courses; Aqua-lung diving; BMX and mountain bike cycling (other than normal road use); Boxing; Canyoning or gorge walking; Cliff or rock climbing; Earth balling; Elastic rope sports or activities; Firework displays; Flying (except as a fare-paying passenger); Fly on the wall; Hang-gliding; Horse riding; Hunting; Ice skating; Javelin throwing; Martial arts; Mechanical fairground amusements/rides; Motor-cycling; Mountaineering; Paintballing; Parachuting; Polo; Pot-holing; Professional sport of any kind; Racing (except on foot); Roller blading; Shooting; Skateboarding; Trampolining; Water activities (except swimming); Winter sports (including dry-slope skiing) and Wrestling. NOTE: IF YOU DO NOT COMPLY WITH THESE STATEMENTS, YOU ARE NOT ELIGIBLE FOR THIS INSURANCE AND ANY COVER GIVEN MAY BE INOPERATIVE Event details: You require cover from:  FORMTEXT       to  FORMTEXT       (include days for preparation, erection, dismantling & removal)Full name of organiser(s):  FORMTEXT      Description of the Event e.g. concert, fete or exhibition including details of planned activities, side-shows etc:  FORMTEXT      Location (venue) address for the Event:  FORMTEXT      Estimated daily attendance for the Event:  FORMTEXT       Number of employees/volunteers involved in the Event?  FORMTEXT      Please refer to the Key Facts summary of cover or the policy wording for details of cover. Public & Products Liability Yes  FORMCHECKBOX   FORMTEXT       million indemnity limitAll Risks Yes  FORMCHECKBOX  No  FORMCHECKBOX  If YES, a) marquees/tents & temporary structures  FORMTEXT       (premises cover only) b) other property:  FORMTEXT       and a single item limit of  FORMTEXT       Cancellation Expenses Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT       Employers Liability Yes  FORMCHECKBOX  No  FORMCHECKBOX Money Yes  FORMCHECKBOX  No  FORMCHECKBOX Personal Accident Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT       /  FORMTEXT       per week Data Protection Act  use of your information: For the purpose of the Data Protection Act 1998, the Data Controller in relation to the information you supply for this insurance is Ansvar, part of the Ecclesiastical Insurance Group. As a data subject you have a right under the Act to ask your Data Controller for a copy of personal data you have supplied and ask for inaccurate data to be corrected. Information you supply is used for purposes of administration by the insurer and its agents, by re-insurers and your agent. It may also be made available to regulators and ombudsmen as necessary. In deciding whether to offer insurance, its terms or assessing claims made, insurers may undertake checks against publicly available information such as electoral roll, county court judgements, bankruptcy or repossessions. Information may also be shared with other insurers either directly or via those acting for the insurer, such as loss adjusters or investigators. 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Declaration by you: You declare that as far as you are aware the above statements made by you, or on your behalf, are true and complete. You agree to accept our: use of the information in this Statement; standard form of policy wording for Neighbourhood Watch Special Events Insurance. Name of proposer:  FORMTEXT      Date:  FORMTEXT      Position held within your Association/Scheme:  FORMTEXT       Policy underwritten by Ansvar Insurance Company Limited Ansvar House, St. Leonards Road, Eastbourne, East Sussex, BN21 3UR Tel: 01323 737541 Fax: 01323 644082     Time/Date Printed:  TIME \@ "HH:mm" 09:59 on  DATE \@ "dd/MM/yyyy" 30/cdx `v]L'($If^'gda7 & F($If^`gdsR & F$IfgdJ9! $IfgdJ9! $IfgdJ9!akd\$$Ifl45&*0*4 laf4T{ e(x$IfgdsR (x$Ifgd\Pakd]$$Ifl45&*0*4 laf4*,.BDFPRT^`bvxzжⓉ}fT:f2j^hdh=v5U\ehr#hdh=v5\ehr,jhdh=v5U\ehrhdh=v5CJ\hdh=v5\ hdh\P7jhdh\P5U\ehmHnHru2j^hdh\P5U\ehr#hdh\P5\ehr,jhdh\P5U\ehr hd5\z @ P¸̸̚sdRdA3Ah>sVCJOJQJ^JaJ h>sVh>sVCJOJQJ^JaJ#h>sVh>sVCJOJQJ\^JaJh>sVCJOJQJ\^JaJhV[CJOJQJ\aJ2j_hdh=v5U\ehr#hdh=v5\ehrhdh=v5CJ\hdh=v5\hdh\P5\,jhdh=v5U\ehr7jhdh=v5U\ehmHnHruy e(x$IfgdsRtkd_$$Ifl405&QR0*4 laf4RVX\^bdhj  $]a$gd$a$gdl$a$gd>sVakd\`$$Ifl45&*0*4 laf4PRTXZ^`dfjʍ̍ r ԃq`M%jh0J5CJOJQJU\ h>sVh>sVCJOJQJ^JaJ#h>sVh>sVCJOJQJ]^JaJhh6CJ OJQJ]^JU+hQS6CJ OJQJ]^JmHnHsH u$h6CJ OJQJ]^JmH sH %jh6CJ OJQJU]^Jh6CJ OJQJ]^Jh-3~jh-3~U hlh>sVCJOJQJ^JaJ03/2006 Registered Office: Beaufort House, Brunswick Road, Gloucester, GL1 1JZ Registered No: 661060 England Member of Association of British Insurers (ABI) and the Financial Ombudsman Service (FOS). 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