Broking Template 26 07 11 by VDH4ZBs


									                                       Broking Template/Statement of Fact:                              CONTRACTORS
Broker’s / Agent’s details
Broker name                                                                   Contact name

Broker address

Telephone number                                                              Fax number

Email address                                                                 Date submitted

Renewal date                                                                  Deadline date

Holding agent                                                                 Last year’s premium         £

Holding insurer                                                               Target premium              £

Proposer’s / Insured’s details
Proposer’s name                                                               PAYE Ref Code (ERN)

Proposer’s address

Address continued                                                             Post code

Website address                                                               Year established

Full Business
Description including
products supplied
(attach relevant
brochures etc)

Other Companies (specify whether dormant, a subsidiary or associated and include any ‘Trading as’ names)

Name (and address if                                                          PAYE Ref Code (ERN)
different from above)

Name (and address if                                                          PAYE Ref Code (ERN)
different from above)

Name (and address if                                                          PAYE Ref Code (ERN)
different from above)

Covers required (Please indicate with X)
Employers Liability                           Public Liability                                Products Liability
JCT Clause 21.2.1 (or equivalent)             Contractors All Risks                           Terrorism

Claims Experience in past 5 years

                                                                                                          Amounts (include any
Date                     Details (include circumstances and post loss action to prevent reoccurrence)
                                                                                                          amounts not yet paid)





                                          Broking Template/Statement of Fact:                   CONTRACTORS

   Is there, or has there ever been, any exposure to asbestos or asbestos containing
                                                                                               Yes / No (delete as applicable)
   materials, including holding a licence to work with asbestos?
   Are you accredited with any quality standard (eg ISO 9002 or similar)?                      Yes / No (delete as applicable)
   Are you approved to carry out your business by the Local Authority?                         Yes / No (delete as applicable)
   Are you a member of any trade association that provides health & safety training and        Yes / No (delete as applicable)

   If Yes, please state the name of the trade association and the services used                ___________________________

   Do you have a full time Health & Safety Officer or Risk Manager?                            Yes / No (delete as applicable)
a) a) Do they have formal Health & Safety qualifications eg MIOSH or NEBOSH                    Yes / No (delete as applicable)
   b) Do they attend regular training courses?                                                 Yes / No (delete as applicable)
   Do you employ a specialist external consultancy?                                            Yes / No (delete as applicable)
   Is there an Accident Book?                                                                  Yes / No (delete as applicable)
   Are all incidents relating to injury, disease and pollution recorded?                       Yes / No (delete as applicable)
   Is there a system in place for near-miss reporting and remedial action to be taken?         Yes / No (delete as applicable)
   Do you follow the Joint Code of Practice for fire prevention on construction sites?         Yes / No (delete as applicable)
   Are hot work permits issued whenever heat is to be used?                                    Yes / No (delete as applicable)
   Is a current written Health & Safety Policy statement in place? (obtain a copy)             Yes / No (delete as applicable)
   Are risk assessments and method statements undertaken?                                      Yes / No (delete as applicable)
   Do your site safety and security arrangements include:
   a) Regular workplace/plant etc inspections                                                  Yes / No (delete as applicable)
   b) Safety notices/instructions being prominently displayed                                  Yes / No (delete as applicable)
   c) Assessment and effective control of pollutants/waste and COSHH                           Yes / No (delete as applicable)
   d) Plant and machinery maintenance programme                                                Yes / No (delete as applicable)
   e) Full site perimeter fencing and boarding                                                 Yes / No (delete as applicable)
   Are full records maintained of each person’s health & safety and occupational competence?   Yes / No (delete as applicable)
   a) Is training provided on a regular basis and signed off by the employee?                  Yes / No (delete as applicable)
   b) Is manual handling and other job related training carried out?                           Yes / No (delete as applicable)
   c) Is site induction provided to all staff including subcontractors?                        Yes / No (delete as applicable)
   d) Are FLT/Plant Drivers trained and certificated?                                          Yes / No (delete as applicable)
   e) Do all employees hold Construction Skills Certification Scheme Cards?                    Yes / No (delete as applicable)
   f) Is Personal Protective Equipment (PPE) supplied free of charge to all employees and      Yes / No (delete as applicable)
      the wearing of PPE a condition of employment?
                                                                                               Yes / No (delete as applicable)
   g) Do employees sign for receipt of PPE?
   h) Do you have a bank of regularly used subcontractors?                                     Yes / No (delete as applicable)
   i) Do you have a procedure to check and vet sub-contractors for quality and health &        Yes / No (delete as applicable)
      safety compliance?                                                                       Yes / No (delete as applicable)
   j) Are the insurance details of all sub-contractors checked and recorded?                   Yes / No (delete as applicable)
   State percentage of the types of premises worked up                                         Commercial _____________%
                                                                                               Domestic _______________%
                                                                                               Other __________________%
   Maximum height worked to for external works:                                                 _________________ Metres
       If above 10 metres, what proportion of work is 10-15 metres                              _____________________%
       And what proportion of work is over 15 metres                                            _____________________%

                                       Broking Template/Statement of Fact:                    CONTRACTORS
State the proportion of your work where you are the main or sole contractor                  ______________________%
Maximum depth worked to:                                                                      _________________ Metres
    Up to 1 metre                                                                             _____________________%
    1 to 3 metres                                                                             _____________________%
    3 to 5 metres                                                                             _____________________%
    Over 5 metres                                                                             _____________________%
Do you use slings or cradles                                                                Yes / No (delete as applicable)
Do you use any other lifting apparatus, hydraulic lifts, cranes, hoists, access plant or    Yes / No (delete as applicable)
equipment? If YES describe use below:
Do you supply advice, designs, formulae or specifications for a fee?                        Yes / No (delete as applicable)

Additional Notes

Limit of indemnity required                                                       £

Public Liability (any one loss) and Products Liability (aggregate)                £

All contracts commencing during the period of insurance and which specify 21.2.1 insurance (or equivalent) as a requirement
will automatically be held covered for up to 28 days, pending notification of details to us. A Supplementary Questionnaire
must be completed for each contract.
If cover is required please state the limit of indemnity required:
Basis of Limit of Indemnity:                 Limit for any one occurrence         £
                                or           In total for the contract            £

                                       Broking Template/Statement of Fact:                  CONTRACTORS
Payments to Staff

Type of work                                    Wages to own staff / labour only    Payments to bonafide sub-contractors
Directors/Partners (non manual)                 £
Directors/Partners (manual)                     £
Clerical                                        £                                   £
Manual – premises                               £                                   £
Manual – away                                   £                                   £
Totals                                          £                                   £

Turnover split by %                             Turnover split (including the value of any free issue materials)

Great Britain                          %        Construction (new)                  £
EU / Northern Ireland                  %        Construction (alteration)           £
North America                          %        Construction (own development)      £
Rest of World                          %        Land purchase cost                  £
                                                Profit on own developments          £
Turnover total                                                                      £
                                                                       Wages to     Payments to bona-       Turnover
High Risk Work (included in above payments)                           own staff &       fide sub-            split by
                                                                      labour only      contractors         percentage
Demolition                                                      £                   £                                 %

Piling                                                          £                   £                                 %

Underpinning                                                    £                   £                                 %

Asbestos removal                                                £                   £                                 %

Plant hire                                                      £                   £                                 %

Roofing, Scaffold erection or Steel erection                    £                   £                                 %

Tunnelling or quarrying or work involving explosives            £                   £                                 %

Woodworking machining                                           £                   £                                 %

Work involving application of a naked flame or open heat
                                                                £                   £                                 %
source, or use of hot air guns or gas space heaters
Work using grinding wheels, angle grinders or disc cutters      £                   £                                 %

Erection of Buildings with over 20m span                        £                   £                                 %

Towers, steeples or spires , viaducts or bridges                £                   £                                 %

Work in, on or around water, docks, piers or wharves            £                   £                                 %

Works “airside”                                                 £                   £                                 %

Work in, on or around railway premises/tracks/property          £                   £                                 %

Work “offshore”                                                 £                   £                                 %

Work in, on or around hospitals, research establishments
                                                                £                   £                                 %
and laboratories
Work involving refineries, nuclear installations, gas or        £                   £                                 %
chemical works
Other - Please specify:                                         £                   £                                 %

TOTAL                                                           £                   £                                %

                                       Broking Template/Statement of Fact:                        CONTRACTORS

Cover                                                                                                All Risks
Maximum contract value                                                                 £
Maximum period of any one contract                                                                               months
Replacement value of own plant, tools, machinery and equipment                         £
Replacement value of own temporary buildings                                           £
Total value of Employees’ Tools and Personal Effects on Site                           £
Maximum value any one Employee                                                         £
Total value of hired in plant at any one time                                          £
Annual hire charges for plant hired IN                                                 £
Annual hire charges for plant hired OUT                                                £
Is Plant hired IN under CPA conditions of hire, or similar                             Yes / No
Is Plant hired OUT under CPA conditions of hire, or similar with insurance arranged    Yes / No
by the customer
Where you hire plant in/out under conditions other than CPA, please attach a copy of the hire contract
Are larger items of plant:
a) fitted with Immobilisers?
b) fitted with Trackers?
c) have Security marks/codes?
c) fitted with Datatag transponders
d) secured by KOSRAN?
Are you a member of the CESAR scheme?
Please specify arrangements for the overnight storage of valuable or portable
equipment eg removed from site, fencing, guarding, secure areas
Provide details of the 3 largest contracts you have undertaken in the past 5 years     Value

Contract 1 __________________________________________________________                  £

Contract 2 __________________________________________________________                  £

Contract 3 __________________________________________________________                  £
Please give details of any regular or ongoing contracts                                Value

Contract 1 __________________________________________________________                  £

Contract 2 __________________________________________________________                  £

Contract 3 __________________________________________________________                  £
Are you, or will you, be involved in the construction of or work on:
a) timber framed buildings?
b) modular buildings?
c) buildings of construction utilising polystyrene?

Additional Notes

                                        Broking Template/Statement of Fact:                      CONTRACTORS
Insurance Declaration
This document is a Statement of Fact showing the information provided to COBRA Underwriting Agencies Ltd and should be
read together with the Policy and Schedule as one contract. By signing this declaration you are confirming that all relevant
information has been fully disclosed and that full and true answers have been given to all questions asked. If you have not
given full and true answers to all questions asked, your insurance may not protect you in the event of a claim. You should keep
a record of all information provided to the insurer for the purpose of entering the contract.
A copy of the completed declaration will be supplied on request within 3 months of its completion.
A specimen copy of the policy is available on request.
Please read carefully the Claims and Underwriting Exchange Register and Data Protection notices.
Insurance History
Have you or any principal, director or partner in the business now proposed or for any previous business ever been insured for
the risks now proposed? If yes, please provide details:

Full names of all directors:

Company registration number:

Previous insurance
For previous insurances have you or any principal, director or partner to be insured had
 a) any proposal or insurance declined, cancelled or refused?                                                     Yes / No
 b) any renewal refused                                                                                           Yes / No
 c) special terms or conditions imposed?                                                                          Yes / No

If Yes to a), b) or c) above, please provide details:

 Are the claims or losses (whether insured or not) as per page 1 of this Statement of Fact?                       Yes / No

 If No, please provide details

                                         Broking Template/Statement of Fact:                       CONTRACTORS
Financial Statement
Have you or any principal, director, partner or person to be insured either personally or in conjunction with any business with
which they have been involved:

 a) ever been convicted of or charged (but not yet tried) with a criminal offence other than motoring               Yes / No
 b) ever been declared bankrupt or the subject of any bankruptcy proceedings, or ever been involved in any          Yes / No
    voluntary or mandatory insolvency or winding up procedures?
 c) ever been the subject of a recovery action by H.M Revenue & Customs?                                            Yes / No
 d) ever been a director or partner in any business 5 years prior to or at the time of and/or after the             Yes / No
    appointment of a receiver or liquidator or dissolution through insolvency?
 e) Within the past 5 years been prosecuted or been served with a prohibition or improvement order under            Yes / No
    Health and Safety or Environmental Legislation?

If Yes to a), b), c), d) or e) above, please provide details:

Other Material Facts
 Is there any other information that you feel material to the underwriting of this proposal for insurance?          Yes / No

If you have answered Yes to this question please provide details in the box provided below:

Claims and Underwriting Exchange Register

Insurers pass information to the Claims and Underwriting Exchange Register run by Insurance Database Services Ltd (IDS Ltd).
The aim is to help them check information provided and also to prevent fraudulent claims. When they deal with your request for
insurance they may search the register. When you tell us about an incident (such as fire, water damage or theft) which may or
may not give rise to a claim, your insurers will pass information relating to it to the register.

You can ask us for more information about this.

You should show this notice to anyone who has an interest in property insured under this policy.

The Law Applicable

You and the Insurers are free to choose the law applicable to this Policy. As the Insurers are based in England the Insurers
propose to apply the laws of England and Wales and by purchasing this Policy you have agreed to this.

Data Protection Act

COBRA Underwriting Agencies Ltd is a wholly owned subsidiary of COBRA Holdings plc. To set up and administer your policy we
will hold and use information including sensitive personal information (this may include such things as criminal convictions and
health information) about you, supplied by you. We may send it in confidence to the insurers identified in the policy.
By signing this form you consent to such use of your personal data including any sensitive personal data.

                                         Broking Template/Statement of Fact:                             CONTRACTORS
Making Yourself Heard

Any complaint you may have should in the first instance be addressed to your Insurance Adviser, then claim office or helpline
as applicable. If you are not satisfied with the way in which your complaint has been dealt with, you should contact COBRA
Underwriting Agencies Ltd at Canterbury House, 2-6 Sydenham Road, Croydon CR0 9XE, telephone number: 020 8256 1930
If the complaint is still not resolved by COBRA/your Insurer, you can approach the Financial Ombudsman Service.
The Ombudsman will only consider complaints if:
- Your Insurers have provided you with written confirmation that their internal complaints procedure has been exhausted
- Your business has a turnover of less than £1,000,000
Referral to the Financial Ombudsman will not affect your right to take legal action.
Full details of addresses and contact numbers can be found within the Policy Wording.


I/We declare that to the best of my/our knowledge or belief the particulars and statements given in this Statement of Fact,
whether written by me/us or by others on my/our behalf and any additional information provided are true and complete and
this information and Declaration shall be the basis of the contract between myself/ourselves and the Insurer that we decide to
place your insurance with.

I/We agree that the Policy, Policy Schedule and Statement of Fact shall be the basis of the contract between me/us and the

I/We have not withheld any material fact and understand that if full and true answers have not been given that this insurance
may not protect me/us in the event of a claim.

I/We confirm that all relevant information that may influence the Insurer in their acceptance of cover and the terms provided
has been disclosed and recorded

I/We agree to accept the Insurers standard form of policy.

I/We understand that the insurers will pass the information on this form about any incident I/we may give details to IDS Ltd so
that they can make it available to other Insurers. I/We also understand that, in response to any of the searches insurers may
make in connection with this application or any incident I/We have given details of, IDS Ltd may pass insurers information it
has received from other insurers about other incidents involving anyone insured under this policy

If all information contained in this document is correct, you should sign, date and return the Statement of Fact to COBRA.

    First Signatory

    Position (PLEASE PRINT)                                                       Date

    Second Signatory                                                              Signature

    Position (PLEASE PRINT)                                                       Date

IMPORTANT – It is necessary for you to inform us of all the facts, which are likely to influence your insurers in the acceptance
or assessment of your insurance. Failure to do so could invalidate this insurance. If you are in doubt whether any fact may
influence your insurers you should disclose it.
IMPORTANT – In order to assist you a large proportion of the Statement of Fact has been completed on your behalf. However it
is essential that you check all the answers given and amend any that are incorrect or complete any that are not provided for. It
is your responsibility for any non-disclosure or mis-representation of any material fact and your attention is drawn to the
declaration above.

          COBRA Underwriting Agencies Ltd is authorised and regulated by the Financial Services Authority (Reference No. 307955)
                    Registered in England No. 4731994 Registered Office: 110 Fenchurch Street, London EC3M 5JT


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