1. This is a Proposal Form for a contract of insurance
relating to certain specified losses incurred during the
currency of this contract, and otherwise to claims first
made against the Insured during the currency of the contract.
2. The online submission of this Proposal Form does
not bind any proposer to effect insurance but the Proposal
Form and any supporting information supplied shall be
the basis of any resulting contract of insurance, and
will be incorporated in the contract.
3. All questions must be answered fully (using separate emails where necessary)
and truthfully be to the best of the proposers' knowledge and belief. If the
proposers consider that any of the questions require knowledge that they do
not have they must indicate this in their answer.
4. All material facts must be disclosed, including any
which might arise or change between the date of the Proposal
Form and the date of inception of any contracts of insurance
based on this Proposal Form. Failure to do so may nullify
any such contract. A material fact is one likely to influence
acceptance or assessment of this Proposal; if the proposers
are in any doubt as to what constitutes a material fact
they should consult their insurance adviser.
5. The proposers should retain a copy of the completed Proposal Form and
all supporting information supplied. On submitting this online form you will
immediately be presented with a copy of the completed Proposal Form in a print-friendly
format. You should print this out and retain it for your records.
6. A specimen copy of the appropriate policy or certificate
wording is available on request.
The insurance cover can be provided only to recognised
charities and churches (registered or otherwise) which
are formally constituted, whether as a trust, an association
or a company. If more than one underlying organisation
is involved in the same or related charitable activity,
all can normally be covered under a single insurance contract
if details of all are provided in this Proposal Form.
The terms 'Charity' or 'Church' herein means each such
organisation; the term 'Trustee' means anyone who is a
trustee, committee member, director or officer (as the
case may be) of the organisation. If an organisation and/or
trustee is itself incorporated and/or if any of the charitable
activity is conducted by a related company, each such
company (as declared in the Proposal Form) and its subsidiaries
and their directors and officers are included in the cover.
1. Name of Charity/Church:
2. Address of principal office:
3. Full names of current trustees:
Contact Name:
Contact Email Address:
Please retype the Contact Email Address here, to reduce the risk of
errors:
Contact Telephone No.:
4. When was the Church/Charity established?
5. The Charity is recognised as a charity and is:
a*) In Scotland and registered under number:
b*) In England or Wales and registered under number:
c*
) In England or Wales but not required to register:
*complete as appropriate (one only)
6. Principal activities:
7. During the last five years
a) has the name changed?
If YES, please give details:
b) has there been any amalgamation or merger with another Charity/Church?
If YES, please give details:
8. a) To what date were the last accounts made up?
Please state period of accounts if other than twelve months:
b) Were those accounts audited or 'independently examined' and given
an unqualified report?
c) State the gross annual income shown in those accounts:
d) State the total gross assets (i.e. fixed assets + investments +
current assets) shown in the last balance sheet
e) If the Charity/Church acts as a custodian trustee, state the total
gross assets in its custody:
9. a) Is any Charity/Church named at (1) above incorporated as a body
corporate?
b) Does any Charity/Church named at (1) above (whether or not incorporated)
carry out any of its activity through any separately incorporated company
(e.g. a trading subsidiary)?
If YES to 9. (a) and/or 9. (b), please state:
i) the name and description of all companies concerned (referred
to collectively hereinafter as 'the Companies'), indicating how and
when each was incorporated (e.g. the relevant legislation or other legal
authority), the relationship between the Charity/Church and the Companies
and the activity carried on by each;
ii) the full name of each person (not already named at (3) above)
who is or is considered to be a director or other officer of any of
the Companies. In each case please also state all such positions held
and in which of the Companies.
SECTION B - PROFESSIONAL SERVICES
Note: The questions in this section must be answered in relation
to any ‘Professional Services’ provided by the Charity.
‘Charity’ for this purpose means any charity, any of the
companies, any present trustee or any present employee of any of them.
‘Professional Services’ means any service such as advice,
information, assistance or design provided to anyone (other than wholly
for the purpose of managing or administering the Charity itself), whether
gratuitously or otherwise. It does not include the supply of any product.
If you are uncertain what in your case constitutes ‘Professional
Services’, please consult Keegan & Pennykid (Insurance Brokers)
Ltd.
10. Does the Charity provide any of the following Professional services:
a) Financial or legal advice?*
b) Counselling?*
c) Medical advice, diagnosis or treatment?*
d) Other?*
*If any answer to Q10 is ‘YES’, please also
answer Q11-15 as appropriate. If all answers to Q10 are ‘NO’,
please go to Section C
11. a) Give details of type of financial or legal advice provided:
b) How many people provide it?
Part Time:
Full Time:
c) What is the qualification/background/experience of the people
who provide it?
d) approximate number of enquiries per annum?
12. a) Give details of the type of counselling provided:
b) How many people provide it?
Part Time:
Full Time:
c) What is the qualification/background/experience of the people
who provide it?
d) approximate number of enquiries per annum?
13. a) Where counselling or financial or legal advice is provided,
give details of present procedures/guidelines which identify situations
where the person being counselled/advised should be encouraged to seek
independent professional advice:
b) Where such independent advice is appropriate, is it usual practice
to recommend one or more named advisors?
14. Give details of medical advice, diagnosis or treatment provided:
15. a) Give full details of other services (e.g. advice, information,
assistance, design) provided:
b) How many people provide it?
Part Time:
Full Time:
c) What is the qualification/background/experience of the people
who provide it?
SECTION C - GENERAL
16. Has the Charity, any of the Companies or any past or present Trustee
been refused this type of insurance or had a similar insurance cancelled?
If YES, please give details:
17. Has any claim that might have fallen within the scope of the proposed
insurance been made during the last five years against the Charity, any
of the Companies or any past or present Trustee?
If YES, please give details:
18. Is the Charity, any of the Companies or any present Trustee aware,
after enquiry, of any circumstance or incident which it or he/she has
reason to suppose might result in any future claim which would fall within
the scope of the proposed insurance?
If YES, please give details:
Please check the wording of this Proposal and the data
you have entered carefully before proceeding by clicking on the 'continue
to next stage: final check' button, below. Clicking on the button will
not submit your details yet, but will cause another page to
load.
The new page that loads will give you a chance to check your data again,
and if you need it you will get another opportunity to make changes
before finally sending the data.
If you notice an error shortly after sending the data (when you see
the page that invites you to print the submitted data out for your records)
you can resubmit a corrected version. After submitting, you can try
using your browser's Back button to return to the form. If you are lucky,
the data might still be displayed, which would save you typing it all
in again.
If you resubmit in this way, please also indicate this here:
Are you resubmitting this form after making a change to a
recent submission?
If you only notice an error later and it is too late
to go back and resubmit, or you find that the data has disappeared from
the form when you return to it, please make a copy of your printed record
and fax it to us along with an indication of the change(s) you wish
to make.
Alternatively, please call us on (0131) 225 6005 and
explain the change(s) you would like us to make for you.
Please note that in such circumstances we may have to send you a form
to fill in on paper and sign in order to confirm changes.
DECLARATION
I
For the purposes of confirmation, please repeat your full name here:
Date:
