B E E C H T R E E E N T E R T A I N M E N T
WOODLANDS OWNERS INSURANCE PROPOSAL FORM
You may return this form by:
a. post to 1 Mill Lane Bungalows, Rodmell, Sussex BN7 3HS
b. e-mail to
Please note when completing this Proposal that all material facts should be disclosed. If in doubt as to whether any fact is material, it should be disclosed. Please ask and we will be glad to advise. (Tel: 01273 475276)
Some of these questions will not be relevant to you or your wood. If so, please mark n/a rather than leaving blank.
Proposer:
Your postal address:
Best address for the wood:
Telephone number:
Nature of Ownership: Is any COMMERCIAL BUSINESS carried on? Yes / No
Date on which insurance is to commence:
COVERS REQUIRED: (Delete as necessary)
Public Liability (includes Products Liability)
Employer’s Liability
PUBLIC LIABILITY:
Limit of Indemnity: £5m
Your wood, meadow or heathland:
What is the annual income from the wood if more than £10,000 pa:£
What is the size of wood, in acres or hectares?
If any commercial work is done, please describe the type of work?
Are there any:
. public rights of way?
. standing areas of water such as ponds or streams?
. barbed wire or similar obstructions on the rights of way?
. derelict or vacant buildings?
. other dangerous hazards, eg, hidden ditches?
Are any public rights of way safely maintained and signed?
Do you host events open to the public, eg, walks, tours, entertainment?
If so, please give details:
EMPLOYER’S LIABILITY:
Limit of Indemnity: £10,000,000
Cover is given free of charge and protects you against allegations made by those working under your control (which is the definition of an employee, rather than if you pay them)
Number of employees, volunteers, casual workers: under ten? More than ten?
Total Wageroll: £ or N/A
Do you or any workers/helpers work at heights above 10 feet? If so, to what maximum height?
Do you or your helpers use chainsaws?
If so, what Protective Equipment do you use?
Do you supply your “workers” with protective equipment?
Does the work involve the discharge of any effluent or noxious fumes or
waste?
Do your activities now (or at any time in the past) involve exposure to noise levels
exceeding 90 decibels, without adequate ear protection?
Do you carry out excavation work or work underground to more than 3 feet depth?
Do you engage sub-contractors to work on your land? If so, what do they do?
GENERAL QUESTIONS:
Has the proposer suffered any insurance losses in this or another name in
past five years or had insurance declined or subject to special terms? If so,
please give details
Has any prosecution, prohibition notice or improvement order been placed
on you under any health and safety legislation during the past five
years?
Has the proposer ever been convicted of, or charged with (but not yet tried)
a criminal offence other than a motoring offence, or been declared bankrupt;
is the proposer the subject of any current bankruptcy proceedings or any
voluntary or mandatory insolvency or winding-up procedures? If so, please
give details
DECLARATION by the PROPOSER:
The information given above is true to the best of the Proposer’s knowledge and belief and all material facts have been disclosed. Furthermore, the proposer undertakes to inform the Insurer of any subsequent changes to all material facts
before and after the effecting of any contract of insurance.
This Proposal and Declaration shall form the basis of any contract between the Proposer and the Insurer.
Signed by the Proposer:
Date:
1
1 Mill Lane Bungalows, Rodmell, Sussex BN7 3HS
Tel/Fax: 01273 475276 Mobile: 0787 965 7243
E-mail:
Beech Tree Entertainment is a trading style of Insurance Experts Ltd.,
Authorised and Regulated by the Financial Conduct Authority,
Registration No. 307379
Prop Doc 6/14