Heating, Ventilation and Mechanical Services Proposal Form

Hv: Heating Ventilation & Mechanical Services Combined Liability Insurance

PROPOSAL FORM MILES SMITH LIMITED BIRCHIN COURT 20 BIRCHIN LANE LONDON EC3V 9DU TELEPHONE 020 7283 0040

MS Heating v.1 (03.2010) RWM

www.milessmith.co.uk www.milessmith.co.uk

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Heating Ventilation & Mechanical Services BIRCHIN COURT 20 BIRCHIN LANE LONDON EC3V 9DU FACSIMILE 020 7220 0862 TELEPHONE 020 7283 0040

www.milessmith.co.uk

Combined Liability Proposal Form Proposers Details 1. Full name of insured (including registered and trading name(s) and any subsidiary companies)

Company number

2. Postal address to be used for all correspondence and address(es) of all branch offices / location

Telephone

Mobile

Postcode(s)

Email address

Website address

3. Full description of trade / business (If you have a brochure or company literature, please attach to this form)

4. Date company established. If new or less than 12 months old, provide details of experience of Proprietor, Partners or Directors.

Yes

5. Has the business changed name in the last 5 years. If Yes provide FULL details of all previous names below

Name of current broker

6. Name of current insurer

No

Renewal date

7. Is your company a member of a professional body or trade association

Cover Required 8. State compulsory covers and limits of indemnity required.

Employers Liability

Yes

No

Limit of Indemnity GBP

Public, Products and Pollution Liability

Yes

No

Limit of Indemnity GBP

Higher limits available on request

9. State optional covers required and limits of indemnity required. Supplementary questionnares are available via link for download from our website Professional Indemnity (above automatic limit)

Yes

No

Complete full proposal form

click here

Contractors All Risks

Yes

No

Complete supplementary questionnaire

click here

Commercial Combined

Yes

No

Complete supplementary questionnaire

click here

Motor Fleet

Yes

No

Contact our Motor Fleet Department

motor@milessmith.co.uk

Personal Accident Benefit

Yes

No

Complete Q.11 of this proposal form

click here for information

Rehabilitation Service Benefit

Yes

No

Complete Q.11 of this proposal form

click here for information

10. Is any section of your existing liability policy underwritten on a claims made basis. If Yes, state date & relevant section below Section of policy

Yes

No

Retroactive Date

11. Number of employees / directors (excluding Proprietor / Partners) including Labour Only Sub Contractors (maximum any one time) MS Heating v.1 (03.2010) RWM

www.milessmith.co.uk

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Estimates of Wages and Turnover 12. Total estimated wages for each applicable category for the forthcoming twelve months Clerical, directors, managerial, sales engaged in non manual activities

GBP

Proprietor / Partners own drawings engaged in manual activities (only complete if not a "Limited" company)

GBP

Proprietor / Partners own drawings engaged in non manual activities (only complete if not a "Limited" company)

GBP

Supervisory

GBP

Own employees / directors manual activities at the Insured's own premises (estimated by category) GBP GBP Labour Only Sub-Contractors manual activities at the Insured's own premises (estimated by category) GBP GBP Own employees / directors manual work away from the Insured's own premises (estimated by category) GBP GBP Labour Only Sub-Contractors manual work away from the Insured's own premises (estimated by category) GBP GBP Payments to Bona Fide Sub Contractors (refer to Q.16)

GBP

13. Total gross estimated turnover for each applicable category for the forthcoming twelve months Turnover - Contracting

UK

GBP

Turnover - Contracting

EU (excluding UK)

GBP

Turnover - Contracting

Rest of World (excluding USA/Canada)

GBP

Turnover - Contracting

North America

GBP

Turnover - Retail / Wholesale

UK

GBP

Turnover - Retail / Wholesale

Exports to EU (excluding UK)

GBP

Turnover - Retail / Wholesale

Exports to Rest of World (excluding USA / Canada)

GBP

Turnover - Retail / Wholesale

Exports to North America

GBP

Turnover - Other (please specify)

GBP

Turnover - Other (please specify)

GBP

Turnover - Other (please specify)

GBP Total Turnover

GBP

14. Total gross actual turnover from your annual accounts for the past three years GBP

GBP

GBP

15. If you have estimated turnover in respect of contracting work outside the UK, state countries where you have worked or anticipate working

16. If you have estimated payments to Bona Fide Sub Contractors, provide details of their activities

17. Do you examine and record the insurance arrangements of bona fide sub contractors as to duration, indemnity limits & exclusions

MS Heating v.1 (03.2010) RWM

www.milessmith.co.uk

Yes

No

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Business Activities 18. Indicate as a percentage of Gross Turnover the extent of work in respect of the following types of premises Domestic

%

Commercial

%

Industrial

%

19. Indicate as a percentage of Gross Turnover the extent of work involving the following activities Activity

Percentage

Additional Information

General heating and plumbing - new installations

%

General heating and plumbing - service, repair and maintenance

%

Refrigeration, cold rooms, stores, chillers and freezers

%

Air conditioning, ventilation and extraction systems

%

Underfloor heating

%

Renewable - wind, solar, ground source heat

%

Ductwork - sheet metals / plastics

%

Electrical contracting

%

Process control systems

%

Computer installations, cabling and telecommunications

%

Security alarms and systems including CCTV

%

Fire and smoke protection systems

%

PAT Testing, inspection and Part P Certification

%

Professional services advice, design and specification provided for a fee

%

Facilities / building services management

%

Other (please specifiy)

%

Other (please specifiy)

%

Other (please specifiy)

%

20. Do you work on or at any of the following a. Towers, steeples, chimney shafts, bridges, viaducts, motorways, flyovers or underpasses

Yes

No

b. Demolition or dismantling of buildings or other structures

Yes

No

c. Airports, airside, on aircraft , other aerial / aerospacial device or aviation system

Yes

No

d. Railway or railway installations for the conveyance of goods or people including any leisure, amusement or funicular railway

Yes

No

e. Mechanically propelled vehicle or trailer

Yes

No

f. Powerstations, oil refineries, gas, chemical or petrochemical plants and fuel depots

Yes

No

g. Nuclear installations or with radioactive substances or other sources of ionising radiation

Yes

No

h. Collieries, mines, quarries, tunnelling or underground work

Yes

No

i. Ships, vessels, water-borne craft or cushioned vehicle

Yes

No

j. Docks, harbours, piers, jetties, dams, resevours, lakes, rivers, water diversion / canals or sea defence

Yes

No

k. Offshore rig, platform or structure (If Yes, complete separate Offshore Questionnaire)

Yes

No

21. If Yes has been answered to the above questions, give full details including estimated wages and turnover for the forthcoming twelve months and clearly indicate which question your answer refers to

MS Heating v.1 (03.2010) RWM

www.milessmith.co.uk

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Business Activities continued 22. Do you carry out excavations at depths exceeding 2 metres below ground level If Yes, what percentage exceeding 2 metres below ground level

Yes %

23. Do you carry out work at heights exceeding 20 metres above ground level If Yes, what percentage exceeding 20 metres above ground level

24. Do you carry out work using heat producing equipment away from your own premise If Yes, what percentage of turnover relates to use of heat

What is the maximum depth worked to Yes

%

%

No metres

No

What is the maximum height worked to Yes

metres

No

Type of heat used

Health and Safety 25. Are you accredited or registered with an approval or certification body in respect of the work undertaken. If Yes, specify below

Yes

No

26. Do you have a written health and safety policy that is available to your staff and visitors. If Yes, complete the following questions

Yes

No

Who is responsible for health and safety within the company What is their position within the company When did you last carry out a health and safety audit / review Name any independent consultants used for advice / audit of policies and systems 27. By what process do you ensure that your health and safety policy is kept up to date

28. Describe the company training and instruction policy with reference to certification, induction training and toolbox talks

29. Describe the company policy on personal protective equipment with special reference to enforcement

30. Describe your accident investigation procedure with reference to processes to minimise likelihood of recurrence following an accident at work

31. Confirm that you always retain the following documentation Health and safety risk assessment records

Yes

No

Instruction and safety training records

Yes

No

Method statements / work instructions

Yes

No

RIDDOR forms

Yes

No

32. Provide any other information regarding health and safety which you believe to be relevant to Underwriters' consideration of this risk

MS Heating v.1 (03.2010) RWM

www.milessmith.co.uk

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Claims Details 33. Detail any incident in the last five years which could have resulted in or has resulted in a claim under the risk which you are now proposing a.

By employees

Date

Nature of injury

Amount paid

Amount outstanding

Amount paid

Amount outstanding

b. By third parties (including incidents arising out of faulty products and/or design) Date

Nature of damage or injury

34. Are any of the Directors, Partners or Proprietors after aware of any circumstances, allegations or incidents which may give rise to a claim against the Firm / Company or its predecessors in business or any of its present or former Directors, Partners or Proprietors. If Yes, provide full details below in the additional information section (Q.35)

Yes

No

35. Any additional information regarding any claims should be noted in the space below

MS Heating v.1 (03.2010) RWM

www.milessmith.co.uk

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General Questions 36. Have you or any of your Partners or Directors been insured in connection with this or any previous business (in this or any other name) against any of the risks proposed

Yes

No

37. Are you or any of your Partners or Directors currently insured in connection with any other business (in this name or any other name) against any of the risks proposed

Yes

No

If you have answered YES to either or both questions 1 & 2, give details of the Insurer(s) and Name(s) of the Business(es) in Additional Information

38. Answer the following questions in relation to this business or any previous business in which you or your Partners or Directors have traded, in this or any other name a) have any insurers declined to insure you or them, cancelled or refused to renew your or their insurance or imposed special terms

Yes

No

b) have there been any incidents in the last five years where the Health and Safety Executive, Environmental Health Office or any other enforcement agency have served any enforcement measures or prohibition notices

Yes

No

a) been declared bankrupt or insolvent, in connection with this or any other business in this or any other name, or been disqualified from being a Company Director or been involved as Owner, Proprietor, Partner or Director with any Company which went into receivership, administration or liquidation

Yes

No

b) been the subject of any County Court Judgement

Yes

No

c) been convicted or charged (but not yet tried) with any criminal offence

Yes

No

d) committed any offence to which you or they have admitted and for which you or they have received an Official Police Caution

Yes

No

39. Have you or any Partner or Director ever:

40. Any additional information regarding questions above should be noted here

Declaration I declare that I am authorised to complete this proposal form on behalf of the business and that, to the best of my knowledge and belief, the statements and particulars in this proposal are true and correct and no material facts have been suppressed or mis-stated. I undertake to inform Underwriters of any change to any material fact which occurs before any insurance based on this proposal is effected and acknowledge that this proposal, together with any other information supplied to Underwriters, shall be the basis of such contract.

Name of Proprietor, Partner or Director

Position

Signature of Proprietor, Partner or Director

Date

The Heating Ventilation and Mechanical Services Product is arranged by Miles Smith Limited. Registered in the UK (registered number 311273) and have their registered office at: xxxxxxxx. Authorised and Regulated by the Financial Services Authority (FSA) under Firm Reference Number 311273 and you can check this number at www.fsa.gov.uk/register.

MS Heating v.1 (03.2010) RWM

www.milessmith.co.uk

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