PROPOSAL FORM

Name: Date of Birth:

Business Address: Post Code:

Correspondence Address: Post Code:

Email Address: Tel No:

State all Business Activities for which cover is required:

List all Qualifications obtained from Premier:

All non Premier qualifications need to be referred to PSP Insurance before cover can be provided. Please provide details overleaf.

Date of Commencement of Cover:

1) Cover Required

Section A Public/Products Liability £2m Yes No

or Public/Products Liability £5m Yes No

or Public/Products Liability £10m Yes No

Section B Employers Liability Yes No

Number of Employees

Section C Personal Accident Yes No

Section D All Risks for Business Equipment Yes No

2) In respect of any of the covers to which the proposal relates:

a) Have any insurers ever declined a proposal, refused renewal,

terminated an insurance or imposed special terms? Yes No

b) Have any accidents, losses or claims arisen whether insured or not? Yes No

c) Have you ever been convicted or charged (but not yet tried) with

a criminal offence other than motoring offences? Yes No

If ‘Yes’, to 2a), 2b) or 2c) please give details overleaf. If you are in any doubt about whether facts are material you must tell us, as failure to do so could affect the validity of your policy.

Please note that if you have accepted any extra liabilities by signing an Agreement or Contract these may not be covered by your Insurance. Please refer to PSP Insurance & Financial Solutions Ltd

DECLARATION

I/We declare that to the best of our knowledge and belief the above statements made by me/us or on my/our behalf are true and complete and will form part of the contract between me/us and the Insurers.

I/We agree to accept a policy in the company’s usual form for these classes of insurance.

A specimen copy of the company’s usual policy is available on request

Signature Date

(Signing this form does not bind you to complete the insurance)

PLEASE RETURN COMPLETED FORMS TO THE ADDRESS BELOW OR EMAIL THE SCANNED FORM TO

TOGETHER WITH PAYMENT BY CHEQUE MADE PAYABLE TO PSP INSURANCE OR BY CARD. A CHARGE OF £2.00 WILL BE APPLIED TO CREDIT CARD PAYMENTS

PLEASE NOTE NO REFUNDS OF PREMIUM ARE GIVEN FOR ANY MID-TERM CANCELLATIONS OF COVER

YOU SHOULD KEEP A RECORD OF ALL INFORMATION YOU HAVE GIVEN TO US

All personal information supplied by you will be treated in confidence by the Royal & SunAlliance Insurance Group of Companies and will not be disclosed to any third parties except where your consent has been received or where permitted by law. In order to provide you with products and services this information will be held in data systems of the Royal & SunAlliance Insurance Group of Companies or our agents or subcontractors. The Royal & SunAlliance Insurance Group of companies may pass your personal data to other companies for processing on its behalf. Some of these companies may be based outside Europe in countries which may not have laws to protect your personal data, but in all cases the Group will ensure that it is kept securely and only used for the purposes for which you provided it. Details of the companies and countries involved can be provided to you on request.


Underwritten by

Royal & SunAlliance Insurance plc (No. 93792)

Registered in England & Wales at St Mark’s Court, Chart Way

Horsham, West Sussex RH12 1XL

Arranged by

PSP Insurance & Financial Solutions Ltd (No. 303461), 20-22 The Bridge, Chippenham, Wiltshire, SN15 1EX

All of whom are authorised and regulated by the Financial Services Authority

NON PREMIER QUALIFICATIONS, INCLUDING DATE OBTAINED AND ACCREDITATION BODY

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