Employer protection proposal form

Full Name of the Firm (include all subsidiaries to be insured)

Full Principal Address of the Firm

Normal Business Activities (include activities of all subsidiaries proposed for insurance)

Main Contact:

Telephone Number:

Company Reg No.

VAT Reg No.

E-mail:

When was the company established?

Enter the current total annual gross wage-roll including commissions and bonuses. You can exclude the Employer’s National Insurance contributions and Employer’s Pension Contributions This should include all Partners or Directors, temporary, part-time or full time employees and any contract workers.

Enter the current number of Workers

Agency

Part Time

Full Time

How many sites does the business operate from? (Please give details if more than one.)

Has any form of Employment Disputes Insurance been held previously or is any currently held?
YesNo

In respect of any similar type of Insurance, has any Insurer ever declined a proposal, refused renewal, cancelled a policy or imposed special terms when applying for such Insurance?

YesNo

In the past three years has there been a need to initiate or defend any actions in respect of an Employment Dispute? (Include Compromise Agreements that did not progress to an Employment Tribunal)
YesNo

Have there been any recent resignations/dismissals/redundancies or are any anticipated in the next year?
YesNo

Is any worker currently off work through an illness or disability that has lasted for more than 30 consecutive days?
YesNo

Is the Proposer aware of any circumstances including any specific act or omission, dispute or other event which may give rise to a claim under the proposed Insurance?
YesNo

In the last three years have you been taken over, merged with, acquired or disposed of any companies or significant business activities, or are any currently under consideration?
YesNo

Are there any other material facts to be disclosed to Insurers regarding this Proposal for Insurance? (Including matters such as formal grievances, formal performance reviews or disciplinary processes involving any partners, directors or other employees)
YesNo

Do you have written disciplinary rules and procedure which apply to all employees?
YesNo

Does the Firm provide written particulars for all employees by means of contracts of employment and staff handbooks explaining matters relating to their employment?
YesNo

Which type of insurance cover is required?
Awards and Settlements and Legal Representation Costsor Awards & Settlements Only

Is Health & Safety Criminal Prosecution required?
YesNo

Which Indemnity Limit is required?
£50,000 AOC £500,000 AGG£75,000 AOC £750,000 AGG£100,000 AOC £1,000,000 AGG£125,000 AOC £1,000,000 AGG

Which policy excess is required?
£500£1,000£2,000£5,000Other £

If you have answered “Yes” to any of Questions 5 to 12 or “No” to Question 13 or 14, please provide the explanatory information here.

DECLARATION

Please consult with your HR/ Personnel Manager prior to signature

We declare on behalf of the firm that, AFTER ENQUIRY, the statements and particulars in this proposal and any other information supporting this Proposal Form are true and that I/we have not mis-stated nor suppressed any material facts. I/We agree that this Proposal Form, together with any other information supplied by me/us shall form the basis of any contract of insurance effected thereon. I/We undertake to inform Insurers of any material alteration to these facts occurring prior to the completion of the contract of insurance or during the period of the contract of insurance. Signing this declaration does not bind the Proposer or Insurer to complete a contract of insurance.

Acceptance of Director/Partner/Principal

Date

Please Print Name and Job Title