CaSE Professional Indemnity
Proposal Form & Statements of Fact
Charities and Social Enterprises
Charities, Social Enterprises, Care & Healthcare Organisations, Community and Resident Groups, Voluntary Groups, Faith Groups, Associations, Societies, Unions, Clubs and other Not-for-Profit and Public Benefit organisations
Returning this form: It helps if you can return the completed form by email to your contact or to . Or you can fax it to us: 0333 800 9838or mail it to: CaSE Insurance, Manor House, 19 Church Street, Leatherhead, Surrey, KT228DNEasy-to-buy Professional Indemnity Insurance for Charities and Social Enterprises.
Available Cover / CaSE Professional IndemnityProfessional Indemnity / Aggregate Limit of Indemnty – options up to £5,000,000
Civil Liability policy wording /
Loss of Documents /
Option - Limit to apply to ‘Any One Claim’ / Optional
1. Policy Period: When would you like this policy to incept (the policy period is for 12 months)? / Inception Date:
Important Note: The Information you provide and Statements of Fact form part of your insurance contract. Statements of Fact are a record of responses you have provided to insurers, and any assumptions we or insurers may have made about you and your organisation which are expressed as responses you have been deemed to have provided to insurers. In agreeing to the Statements of Fact, you are approving the record of responses you have made, and agreeing to the responses you are deemed to have made. The information recorded in this document is material to Insurers’ assessment of your eligibility for this insurance, the terms and conditions applying to your Policy, and the premium charged. Please therefore check your responses carefully. If any of the information is incorrect please advise us immediately – failure to do so could result in a claim being repudiated or invalidate the Policy from inception.
2.Your Details
Full name of your organisation including any trading name(s):
Full Postal AddressIncluding Postcode:
Your Contact details: / Name:
Email:
Day-time telephone:
Your web-site address(es): /
CaSE Insurance is a trading name of CaSE Insurance Services Limited. Appointed representative of aQmen Limited.
Authorised and regulated by the Financial Conduct Authority. To check these details on the Financial Services Register:
Registered in England: Number 07456845. Registered Address: Manor House, 1 The Crescent, Leatherhead, Surrey, KT22 8DY
CPI1-2/P: KP25.001Page 1 of 4
3.Limit of IndemnityPlease select the Policy Limit you require (the Limit will apply in the aggregate for the Period of Insurance): / £100,000
£250,000
£500,000
£1,000,000 / £1,500,000
£2,000,000
£3,000,000
£5,000,000
Do you require the Limit to apply on an ‘Any One Claim’ basis instead? An increase will be applied to your premium. / Yes / No
4.Principals, Employees, Volunteers, and ConsultantsPlease provide the following information in respect of Principals, Employees, Volunteers, and Consultants employed or engaged by you:
Description / Numbers employed or engaged
4.1 / Trustees / Partners / Directors / Principals, and senior staff
4.2 / Employees and Volunteers
4.3 / Consultants contracted by you, and for whom you wish to provide cover under your policy
Other: please provide a brief description
4.4
4.5
5.Your income: The Annual Income of your organisation during the last Financial Year (or next financial year if a full year has not yet been traded) – includingany subsidiary entities intended to be insured under this Policy:
Up to £25,000 / / £500,001 - £1,000,000 /
£25,001 to £50,000 / / £1,000,001 - £5,000,000 /
£50,001 to £100,000 / / £5,000,001 - £10,000,000 /
£100,001 to £250,000 / / Over £10,000,000 /
£250,001 to £500,000 /
Please confirm you do not expect the above Annual Income for the current Financial Year to vary by more than 25% from last Financial Year: /
If no, please provide details:
Your Largest Single Client: Annual Income from services(under a contract for services or funding agreement):
Up to £5,000 / / £25,001 - £50,000 /
£5,001 to £10,000 / / £50,001 - £100,000 /
£10,001 to £25,000 / / Over £100,000 /
6.Activities: Please provide a description of your general business, and details of the professional, advisory, consulting or counselling services which you wish to insure under this Policy.
Now please confirm the following Statements(if you are unable to confirm any Statement, or need to add any comment, please do so in the space provided below):
7.Statements of Facts / Confirm?SF1Claims or Circumstances / You confirm that you are not aware of any claim which would be covered by this proposed insurance policy (nor of any circumstance which may give rise to such a claim) having been made against your organisation, or by your organisation to insurers, during the past 5 years.
If you have answered 'No', please provide full details of all claims (even if they were declined by your previous insurers) including the number of claims, the nature or circumstances of the claim(s), the approximate date of claim(s) and all paid and outstanding amounts. If any claim has been paid or estimated at £5,000 or more, or if you have experienced any series of three or more claims which involve similar loss or circumstances, please explain what measures you have taken to avoid a reoccurrence of such circumstances. /
SF2aYour Organisation / You confirm that:
1. you are a Charity or Social Enterprise; and
2. you have no other entities (e.g. subsidiary trading companies) for inclusion under this insurance. /
SF2bYour Principals / You confirm that no trustee, governor, council or committee member, or partner, executive and non-executive director or officer has ever in connection with this or any other business been:
1.convicted of or charged (but not yet tried) with any criminal offence other than Motoring offences or spent convictions under the Rehabilitation of Offenders Act 1974;
2.declared bankrupt or insolvent;
3.a trustee or director or partner of a charity or company that went into liquidation or receivership;
4.the subject of a recovery action by Customs and Excise or the Inland Revenue;
5.the subject of a County Court Judgement. /
SF5bMedical Treatment / You confirm that you do not provide (and you are not responsible for any premises or facilities - whether residential or otherwise - used for the provision of):
1. any form or type of medical, clinical or surgical advice, diagnosis, treatment, remedy or procedure;
2. the production, dispensation, sale, supply, administration or prescription of drugs or medicines;
3.any procedure requiring a Special Treatments Licence;
4clinical trials or similar of any kind
by any professionally qualified nurse or medical or dental practitioner acting in their professional capacity. /
SF8aProfessional Indemnity
Regulated Qualification / You confirm that you do not undertake work by Trustees, Partners, Directors, Principals, employees, consultants (whether employed or otherwise) or volunteers acting in their capacity as individuals qualified and/or regulated by the Law Society or Solicitors Regulation Authority, a recognised accounting body, the Financial Services Authority, Royal Institute of British Architects, Royal Institute of Chartered Surveyors, any professional medical or psychiatric organisation, or other similar professional or regulating bodies. /
SFc8bProfessional Indemnity
Services for Fees and Overseas / You confirm that you do not provide advisory or consulting services:
1.for a fee charged to a Service User.
2.to Service Users overseas. /
Claims Made Cover - Retroactive Date(s) / This policy is on aClaims Madebasis. If you currently have similar cover on a Claims Made basis, it is your responsibility to inform us of theRetroactive Date(s)applicable to such cover before this policy incepts (if no date is advised to us, the date(s) applied will be the inception date of this Policy). /
You confirm you do not wish to inform Insurers of any Retroactive Date(s) for Professional Indemnity; /
OR:You confirm that you currently have a Professional Indemnity policy and that the Retroactive Date(s) on such Policy is / are: / Date(s):
If you wish to add any comments or amend any of the above Statements of Fact, please do so here:
Additional Information and Material Facts: If you would like to provide any additional information to the above Application, or advise any Material Facts, please do so here. Please include any requests for Additional Insurance Requirements not provided by this CaSE Combined insurance policy.Material Facts
You have a duty to act with utmost good faith and to disclose material information to insurers. Any fact or circumstance which is known to you (or which ought to be known to you in the ordinary course of your business) is material to the risk if it would influence the judgment of a prudent insurer in determining whether to accept the risk, and in fixing the premium for the risk. If there are any material changes to your business, or to the risk that underwriters are insuring, during the period of the policy then this may give rise to a fresh duty of disclosure to insurers. This duty to disclose all circumstances material to this insurance therefore exists both before this insurance commences and throughout the duration of the insurance contract. The effects of failing to disclose material facts to insurers may vary depending on the Law applicable to the policy in its entirety. If you are in any doubt as to whether a fact is material or not then we recommend that you disclose it to insurers. All questions must be answered fully and truthfully to the best of your knowledge and belief. All Special Circumstances (Material Facts) must be disclosed, including any which might arise or change between the date of this quotation and the start date of any contract of insurance based upon this quotation. If you consider that any questions require knowledge which you do not have or are not sure of, you should contact us to outline your concerns.
Material Facts:
Your Declaration
1.I/We declare that to the best of my/our knowledge and belief:
a)the above Statements of Factand other particulars, whether written by me/us or by others on my/our behalf, are true and complete;
b)any Statements of Factand other particulars which have been given separately by me/us or by others on my/our behalf are true and complete;
c)I/We have not withheld any material fact;
2.I/We agree that this proposal and declaration and any information given separately shall be the basis of the contract between Insurers and myself/ourselves.
3.I/We agree to accept Insurers’ standard form of policy for this type of insurance.
4.I/We understand that Insurers reserve the right to decline any proposal.
5.I/We understand that Insurer’s share information with each other, credit reference agencies and other information agencies with regard to credit agreements, insurances and claims, primarily to assess risks, handle claims and prevent fraud. I/We consent to this.
Authorised signature / Title / Date
We recommend that you keep a record, including copies of this quotation and all information supplied to us for the purpose of entering into this contract.
Cover does not commence until the proposal has been accepted by the Insurers. The Insurers reserve the right to decline any proposal.
Law applicable: Unless specifically agreed to the contrary the contract will be subject to English law.
Receiving information from CaSE Insurance:
CaSE would like to contact you by letter, email or telephone about future quotations, or about products, information or events from CaSE that we believe would be of interest to you. We keep such communications to a minimum.
If you prefer not to be contacted, please tick this box.
Enquiries: Pleasecontact . Tel: 0333 800 9838. Fax:0333 800 9848CaSE Insurance, Manor House, 19 Church Street, Leatherhead, Surrey, KT22 8DY
CPI1-2/P: KP25.001Page 1 of 4