EVENT(S) LIABILITY INSURANCE PROPOSAL FORM

Before answering the questions contained in this proposal please bear in mind that the answers given and any statements made will form the basis of any contract of Insurance that may result from the completion of this form

Please answer all questions. If you have insufficient space to answer fully please use separate sheet(s)

  1. Name of Proposer ______

Address______

______

______Postcode ______

Occupation______

Daytime Telephone ______Fax Number ______

  1. The Event(s) Organiser's details (if other than Proposer)

Name ______

Address______

______

______Postcode ______

Occupation______

Daytime Telephone ______Fax Number ______

3.State the experience of the Organiser of this Event with events of the type and size proposed

4. State interest of the Proposer (i.e. the person to be indemnified) in the Event(s) to be insured (e.g. organiser)

5.Has the Proposer ever been

a)declared bankrupt?YesNo

b)disqualified from being a Company director?YesNo

c)involved as an owner, director or partner with any Company that went into receivership, administration or liquidation? Yes No

d)convicted (or charged but not tried) of any criminal offence involving dishonesty of any kind? Yes No

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6.Do you require Public Liability insurance? YesNo

7.Do you require Employers Liability insurance? YesNo

8.State:

a)The title of the Event(s) ______

b)The full description of Event(s) (Please list all the activities that will take place at the Event(s)

c)The Venue(s) of the Event(s) ______

d)Is/are the Venue(s)

i)indoorsYesNo

ii)outdoorsYesNo

iii)under canvassYesNo

iv)a temporary structureYesNo

v)a combination of any or all of the aboveYesNo

If the answer to Question(s) 6 d) ii), iii) or iv) is YES, please give full details of the Venue site

If the answer to Question 6 d) v) is YES, please give full details including the Venue site and attach descriptive brochure if available

9. a) Period at Venue(s) From: ______to: ______(both days inclusive)

(including the set up and get out time)

b) Actual date(s) of the Event(s) From: ______to: ______(both days inclusive)

10. Has this/have these Event(s) been held (or planned to be held) before? Yes No

If YES, please state how many times / years

11. State Public Liability Limit Required£1,000,000£2,000,000£5,000,000

12. State Estimated Attendance per day of the Event

13. State the number of stewards that will be used to ensure the safe running of the event.

14. Will the police or a security company be in attendance? YesNo

If NO, please provide details.

15. Is the Venue a secure site?YesNo

If NO, please provide details.

16. Will alcohol be allowed on the venue site?YesNo

17. Will alcohol be sold during the event? YesNo

18. Is/are the Event(s) part of a larger simultaneous Event(s)? YesNo

If YES, give full details

19. Will there be any of the following at the Event(s)?

a)Celebrities(s) YesNo

b)Fairground / Amusement RidesYesNo

c)Bouncy Castle(s)YesNo

d)Motorised / Mobile / Water bound or Aerial Displays or ProcessionsYesNo

e)Fireworks or ExplosivesYesNo

f)Stunts / Racing or any kind of Hazardous Activity YesNo

If any answer is YES, give full details (including name(s) of Celebrity (ies))

20.If the answer to Question 19 b) – f) is Yes, will there be any Public ParticipationYesNo

  1. If the answer to Question 20 is Yes, will this be provided SOLELY by an

independent party (ies)YesNo

  1. If the answer to Question 21 is

Yes, will you check to ensure that such independent party (ies) have Public Liability insurance with a limit of indemnity at least equal to that requested above and will you check to ensure that such insurance is current for the entirety of the Event(s) Yes No

No, (that is you will at least partly provide such activities) will you ensure that all participants sign written disclaimers Yes No

23.Will any grandstand, tiered seating or similar structure be provided for spectatorsYesNo

If Yes,

a) What is the capacity______

b) Who will erect the structure______

c) Will you ensure that the erectors are made responsible for Public Liability insurance and that such insurance has a limit of indemnity at least equal to that requested above and will you check to ensure that such insurance is current for the entirety of the Event(s) Yes No

d) Will the structure be inspected by a local authority of other qualified surveyorYesNo

  1. Will suitably qualified staff provide First Aid and will they be in attendance

at the Event(s)YesNo

25. If you have answered YES, to Question 7 (Employers Liability is required for the Event(s) Please state

a)the activities to be undertaken by employees (and casual staff) at the Event(s)

b)the wage roll split between: Clerical Staff: ______All Others: ______

c)the number of Casual Staff employed at each of the Event(s) ______

26.Has/have the Event(s) been held before, under present management or any other? YesNo

If YES, give full details

27. Has/have the Event(s) ever suffered a loss? YesNo

If YES, give full details including Date(s), Cause(s) and Loss (£)

28. Has the Proposer ever suffered a loss whether insured or otherwise in respect of his/her involvement in any type of Event? Yes No

If YES, give full details including Date(s), Cause(s) and Loss (£)

29. Are you aware of any matter, fact, circumstance or incident existing or threatened that might result in a loss under this insurance? Yes No

If YES, give full details

IMPORTANT NOTICE

Please note that failure to disclose all material facts (that is those facts an insurer would regard likely to influence the acceptance or assessment of this proposal) may invalidate the Insurance. If you are in any doubt whether a fact is material you should disclose it. You are advised to keep a record (including copies of letters) of all information supplied to the Insurer for the purpose of entering into the contract of Insurance. A copy of the completed proposal form is available on request for a period of 3 months after it's completion

Insurance Premium Tax - General Insurance Business

The Finance Act 1994 requires us to levy Insurance Premium Tax at the current rate on most classes of General Insurance Business effected on or after 1st October 1994. For further information, please contact your Insurance Advisor.

DECLARATION

1/We declare that the particulars and statements given in this Proposal and the information provided are to the best of my/our knowledge and belief complete and true and 1 am/We are willing to accept the Certificate of Insurance issued by Worldwide Hole ‘N One Ltd on behalf of certain Lloyd’s Underwriters including its terms conditions and exclusions

Signature: Date:

Name (in block capitals) Position:

Document PPL tba3

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