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Name of Organisation:
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Address:
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Postcode:
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Telephone Number:
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Email Address:
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Website Address:
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Type of Organisation (please tick one or more):
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Recognised Charity
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Applying for Charitable Status
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Registered Charity
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Limited by Guarantee
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Charitable Incorporated Organisation
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Voluntary Organisation
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Not for Profit Organisation
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Other, please describe:
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Number of Years in Business:
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Activities of the Organisation
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Please describe the full scope of works undertaken in the UK by staff and volunteers
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Please describe the full scope of works undertaken overseas by staff and volunteers
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Claims History:
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Please list the countries where you have projects
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Does your organisation have any assets or representation or
any associated or subsidiary operations outside the UK?
(If YES, please provide details)
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Yes
No
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Please list countries:
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Does your organisation manufacture products?
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Yes
No
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If YES, will any of these products be supplied directly or indirectly to the USA/Canada?
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Yes
No
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Please give details of the products:
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Is Products Liability Required?
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Yes
No
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Annual Income
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About your Staff and Volunteers
(Please provide number, nationality and annual wage roll where appropriate for each of the
following categories of employee & volunteer. Approximations are acceptable.)
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Staff and Volunteers within the UK
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Clerical/Managerial
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Manual - please decribe the nature of the work
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Staff and Volunteers working overseas
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Clerical/Managerial
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Manual - please decribe the nature of the work
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*Indigenous – "The original inhabitants of an area and their descendants, i.e. local residents".
Please note: Information regarding employment of indigenous staff/volunteers is
required but we are unable to cover indigenous staff/volunteers and cover
would need to be arranged locally.
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Are any of your Volunteers/Staff under the age of 18 or over the age of 70?
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Yes
No
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If yes, please advise ages and duties undertaken
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Tell us about your trips overseas
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(a) What is the average duration of trips?
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(b) How many trips are undertaken in a year?
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*Please note where staff are working overseas for prolonged periods,
you should check to see whether cover is required within country
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Do you have a written Health & Safety Policy, and are all categories of
employee/volunteers aware of it? (If YES, please provide a copy)
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Yes
No
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Do you carry out risk assessments? (If YES, please provide a
sample of your current risk assessment)
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Yes
No
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Do you provide Personal Protective Equipment (PPE)?
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Yes
No
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What is the MAXIMUM height worked to? (above ground level)
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What is the MAXIMUM depth worked to? (below ground level)
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Who has day to day responsibility and control of your overseas project?
(is the project under your control or the control of a local contractor or charity within country)
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What training/qualifications do those overseeing projects have?
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Limits of Indemnity Required
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Employers' Liability
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£10,000,000
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Public Liability
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£2,000,000 £5,000,000
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Product Liability (if required)
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£2,000,000 £5,000,000
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DECLARATION
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Please read the Declaration carefully and then sign below. If there is
more than one Proposer, both should indicate that they have read the form and verify the
truthfulness of its contents.
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Name of Proposer 1:
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Position in Company:
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I declare that the answers given to questions asked in this Proposal are
true and complete to the best of my/our knowledge and belief.
I understand that if I/we have not given full and true answers to all questions asked on this
proposal that my/our insurance may not protect me/us in the event of a claim.
I understand that any material fact which is information that may influence the Company in
the acceptance of this insurance and the terms provided has been disclosed and recorded.
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Proposer 1: check this box
to indicate that you have read and accept the declaration on the left.
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Name of Proposer 2:
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Position in Company:
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I declare that the answers given to questions asked in this Proposal are
true and complete to the best of my/our knowledge and belief.
I understand that if I/we have not given full and true answers to all questions asked on this
proposal that my/our insurance may not protect me/us in the event of a claim.
I understand that any material fact which is information that may influence the Company in
the acceptance of this insurance and the terms provided has been disclosed and recorded.
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Proposer 2: check this box
to indicate that you have read and accept the declaration on the left.
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No cover is in force until the Proposal has been accepted by the Insurance
Company.
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If you have not given full and true answers to all questions asked on this
questionnaire, your insurance cover may not protect you in the event of a claim.
If you wish to disclose something that has not been disclosed elsewhere on this Proposal,
please give details below.
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