Insurance Underwriting Site Survey Form - DOC

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Insurance Underwriting Site Survey Form - DOC Powered By Docstoc
					Building Contractors and Allied Trades

New Business Risk Submission Form




Underwriting L




imited is a Provisionally Accredited Lloyd's Broker.




Crest Underwriting Ltd is a Provisionally Accredited Lloyd’s Broker
Crest Underwriting Limited is regulated by the Irish Financial Services Regulatory Authority as a Multi Agency Intermediary.
Crest Underwriting Limited is not itself an insurance company and does not underwrite any risk in respect of any policy
arranged on the basis of the information contained or attached to this proposal form.

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The undernoted form can be completed as a submission form or, as we are aware that brokers
produce their own risk submissions, the following should be used as a checklist in respect of
information to be contained in the brokers submission.

The information requested below is the minimum required by London Market in order to obtain a
quality quotation. Any additional information that can be provided where relevant will obviously
assist but we must reiterate that the information requested below is the minimum required.


The General Information and Risk Management Information Sections must be completed in full in all
cases.
The Risk/Financial Information Sections must be completed in full for each separate business class
being considered.



GENERAL INFORMATION:


 Date of Submission:                               Renewal Date:

 Current Intermediary:                             Current Insurer:

 Premium Last Renewal: €                           Target Premium: €




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Proposer Name:
How long has the Business been in existence:

Address:


Risk Location (s):


Full Business Description:




Provide a percentage split of your activities between:

1.   Construction of PDHs/Shops:
2.   Repair, alteration or renovation of PDHs/shops:
3.   General Building:
4.   Civil Engineering:
5.   Allied Trade (eg. Plumbing etc) please specify:

Please supply details of Contracts currently to hand
       Contract                 Nature                   Value                  Location
1.                       1.                      1.                      1.
2.                       2.                      2.                      2.
3.                       3.                      3.                      3.
4.                       4.                      4.                      4.
5.                       5.                      5.                      5.

Please supply details of the three largest Contracts undertaken in last 3 years:
       Contract                  Nature                   Value                  Location
1.                        1.                      1.                       1.
2.                        2.                      2.                       2.
3.                        3.                      3.                       3.




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RISK MANAGEMENT INFORMATION:
Date of last survey
(attach survey report if available):

Who carried out survey (Insurer/Broker?):

Detail any outstanding recommendations:


If any, why are recommendations outstanding:

Do you have a full-time Safety Officer or Committee:

Do you have a Safety Statement:

Are your works Machinery and Plant properly fenced and guarded and otherwise in good
order:

Do you operate a strict permit to work system in respect of:

1. Hot Work:
2. Machinery Maintenance:
3. Other Hazardous Activities (please specify):

Do you own any land for development purposes:
(if yes please list the location and size of such land)
1.
2.
3.

Is such land properly secured to prevent access by third parties? If so, please provide details :


Please confirm that there is a system in place to check the existence and adequacy of the
insurance arrangements of Bona Fide Subcontractors :

Who has responsibility on site to ensure no contractors are engaged until their insurance
arrangements are verified in accordance with the system :

Please provide EL and/or PL Claims Triangulation where possible.

If recurring claims history, please state what action taken by the Proposer to prevent
recurrence.




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SECTION A.                   LIABILITY – Risk / Financial Information
This section must be completed in full where Liability is being considered.

PROJECTED EMPLOYEE PAYROLL
Category of Employee                    Number Employed                       Payroll
Clerical
Direct Employees
Labour Only Subcontractors
Working Directors
- Clerical
- Supervisory
- Manual

NB: The Labour Only Subcontractors category must include any contractor engaged to provide labour
only services irrespective of whether or not such contractor carries their own insurance

HISTORY OF PAYROLL - 5 YEARS
 Year                    Number Employed                  Payroll




E.L. CLAIMS - 5 YEARS (Please attach up to date detailed experience)

 Year               No. Settled      Amount         No. Outstanding       Estimate       Total




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PUBLIC LIABILITY PROJECTED TURNOVER
Provide full details of the Insured’s turnover
broken down between the Insured’s activities
                       Activity                                    Turnover
1. Construction of PDHs/Shops                     1.
2. Repair/alteration/renovation of PDHs/Shops     2.
3. General Building                               3.
4. Civil Engineering                              4.
5. Allied Trade (eg Plumbing) please specify      5.
Total :                                           €

Please provide details of payments to Bona        €
Fide Sub-Contractors:




HISTORY OF TURNOVER - 5 YEARS
 Year                                                          Amount




P.L. CLAIMS - 5 YEARS (Please attach up to date detailed experience)

 Year              No. Settled       Amount      No. Outstanding    Estimate   Total




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SECTION B                 - CONTRACTORS ALL RISKS

CONTRACT LIMITS/SUMS INSURED
Please specify the Contract Limits/Sums Insured required for each of the following

              Item                         Total Value               Maximum value any one
                                                                         Contract/Item
Contract Works
Own Plant
Hired in Plant
Temporary Buildings


C.A.R. CLAIMS - 5 YEARS (Please attach up to date detailed experience)
 Year                No. Settled       Amount    No. Outstanding       Estimate         Total




DETAILS OF COVER REQUIRED
Policy Type                                       Limit of Indemnity
EL
PL
CAR

CLAIMS HANDLING:
Has the Proposer any existing relationship with Loss Adjusters or Solicitors in relation to
claims handling that they would like to continue with ?

If yes, please provide details below




DECLARATIONS:


Are Wageroll & Turnover Declarations up to date?
(If no specify the periods for which declarations are outstanding)




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DOCUMENT INFO
Description: Insurance Underwriting Site Survey Form document sample