Electrical Proposal Forms Birchin

							                                         Birchin Court, 20 Birchin lane, London EC3V 9DU.
                                           Telephone: 020 7283 0040 Fax: 020 7220 0862


                ELECTRICAL CONTRACTORS INSURANCE SCHEME
Full Trading Name including
Partners & Subsidiary Companies

Address including Postcode



Full Business Description

Year Established
Trade Association Membership

LIABILITY SECTION
Current Insurer                                                            Renewal Date:

Limit of Public/Products Liability cover required                          £


ESTIMATES FOR FORTHCOMING 12 MONTHS:

                                                                 Number          Payments             Rate           Premium
Clerical Wages
Partners/Directors working manually
Manual Employees at own premises
Manual Employees work away : Industrial
Manual Employees work away : Domestic/Commercial

Labour Only Sub-Contractors: Industrial
Labour Only Sub-Contractors: Domestic/Commercial
Bona Fide Sub-Contractors:
Estimated Annual Turnover :           Industrial
                        Domestic/Commercial
Pure Sales Split

Non-U.K. Turnover


                                                                               Current Year       Last Year       Year Before Last
Previous Years’ Turnover:      Industrial
                    Domestic/Commercial
Please give details of work / sales outside U.K. including countries / overseas subsidiaries


Do you issue N.I.C.E.I.C. / I.E.E. Certificates If Yes, please complete (a) and (b):                                YES / NO

                                                                                               Tick           Approximate Number

      (a)   Please give details of Certificates Issued:
                 1. Emergency lighting inspection & Test Certificates
                   2.   Petrol Filling Station Certificate of Inspection & Testing
                   3.   Fire alarm System Inspection & Test Certificates
                                                                                         £
      (b)   Estimated Fees for all Inspection / Testing Contracts only
            (i.e. where no installation has been carried out by yourselves)




Proposal Forms/M0145/0806


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TYPE OF WORK BY PERCENTAGE
Electrical         %  Theft Alarms                               %*     Fire Alarms            %*     Heat & Vent             %

Aerial Erection               %     Plumbing                     %      Computer Cabling       %

Other (please give details)                       %




Type of Property:                 Domestic                       %    Commercial               %      Industrial              %


Hot work Away – Welding                                          %    Blow Lamps excluding Soldering Irons                    %


External Height Work                                             %
(above 3 storeys)

Work at hazardous locations? If unsure, state locations worked upon:




State largest 5 contracts in the last 12 months:




* Alarms – Type of premises, i.e. hotels, hospitals, schools etc. Do you commission and/or test or is this done by another?




Please state types of properties and details of work over 240 volts




CONTRACTORS “ALL RISKS” SECTION


Current Insurer:                                                             Renewal Date:


Value of own Plant, Equipment and Tools           £                          Maximum Any One Item      £


Employees Tools & Effects per person              £

Hired in Plant Charges per annum                                             Maximum Any One Item      £


Value of Unfixed Non Ferrous Metals               £
any one site




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Maximum Any One Contract Limit                    £

Please provide details of site huts / Containers used on site:




PREVIOUS RECORD – SECTION TO BE COMPLETED IN ALL CASES:


      1.    Has the Propose or any partner or director of Proposer ever traded in another name?              YES / NO


      2.    Has the Propose or any partner or director of the Proposer

                  (a)   ever been convicted or charged (but not yet tried) with a criminal        YES / NO
                        offence other than a motoring offence?


                  (b)   Received an official caution for a criminal offence (other than a         YES / NO
                        mooring offence) within the last three years?


      3.    Has the Proposer or any partner or director of he Proposer ever been                  YES / NO
            declared bankrupt whilst being a director of a company which went into
            liquidation?


      4.    Has any Insurer in respect of the Proposer or any partner or director of the
            Proposer ever:
                                                                                                  YES / NO
                  (a)   Declined a Proposal?
                                                                                                  YES / NO
                  (b)   Cancelled or refused to renew a policy?
                                                                                                  YES / NO
                  (c)   Increased the premium or imposed special terms?
                                                                                                  YES / NO
                  (d)   Requested extra precautions to be taken (e.g. security or fire)?

      5.    Have you or any of your Directors or Employees ever been:

                  (a)   Prosecuted under any of the Acts or regulations?                          YES / NO
                  (b)   Served with a Prohibition Notice?                                         YES / NO




Proposal Forms/M0145/0806


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Claims - Please give details of all losses in last five years:




                                          DECLARATION : To be completed in all cases.
Important Notice:
Failure to disclose materials facts could result in your policy being invalidated. Material facts are those which might influence the
acceptance or assessment of your proposal. If you are in any doubt as to whether a fact is material YOU MUST DISCLOSE IT.

I/WE hereby declare that to the best of my/our knowledge all the statements given on this Proposal Form are true and complete and that
I/We have disclosed all material facts that ought to be communicated to the Insurers.

I/We hereby declare that if anything on this form was written b y another person he or she acted as my agent for this purpose and I/We have
checked and confirm the accuracy of the information given.

I/We undertake to exercise all ordinary and reasonable precautions for the safety of the insured property.

I/We hereby agree that this Proposal and this Declaration shall be the basis of the contract of insurance between the Insurers and myself /
ourselves.


Position Held


Date:                                                            Signature :




Proposal Forms/M0145/0806


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