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					                        Directors and Officers Liability (Residents’ Associations)
                                                                    proposal form
Date produced on :
Quote required by :

Intermediary details (to be completed by your insurance intermediary)

Intermediary Name :
Address :




Postcode :
Contact person :
Direct Telephone no (inc code) :
Email address :

Existing Insurance Details

Does the Association or any director or officer currently have or have they previously had            Yes/No
any other Directors and Officers Liability insurance cover in place?

If Yes, please state:
Name of insurer :
Periods of Insurance:                                            Limit of Indemnity :

Important notes

Please read these notes carefully before answering any questions.

(A) This proposal should be typed or completed in ink. Please answer every question fully as incomplete
    answers may not be sufficient and can cause delay. If necessary please attach separate sheets with
    information which will be incorporated into your proposal.

(B) Whoever fills out the proposal must be a director or officer of the Association and make all the
    necessary enquiries of their fellow directors and officers to enable all the questions to be answered.

(C) Wherever we ask questions on this proposal form and declaration about you or your Association we
    mean any directors or officers or any former directors or officers of any Association detailed in Your
    Details of this proposal (see B above) for which cover is required under this insurance.

Please also include the latest annual report and accounts and/or financial statements with this
proposal form.




                                                      1
Your Details

Name of the Association to be
insured:
(See important note C)

Registered address :




Postcode :

Address of residential
properties if different from
above




Claims experience

Has any claim ever been made or prosecution brought against you in respect of any neglect, error,         Yes/No
omission or other wrongful act committed in the capacity of director or officer whether in relation to
the activities of the Association, or any other Association in you hold or have held office?

If Yes, please provide the following details of each incident :
Date of       Brief description of claim                        Total payments    Total outstanding      Open/
intimation                                                      including costs   reserves               Closed




Have all claims been notified to Insurers?                                                                Yes/No

Are you aware, after enquiry, of any circumstance or incident which might:
give rise to a claim against the Association or any director or officers of the Association?              Yes/No
otherwise affect the Insurer’s consideration of this insurance?                                           Yes/No

General Information

Have you ever been refused Directors and Officers Liability insurance or quoted increased                 Yes/No
premiums or special conditions?

If Yes, please provide details :




Your cover requirements

Please state the limit of indemnity you require :                                               £




                                                        2
Your Association

When was the Association first established?

Is the Association a non-profit making organisation?                                                     Yes/No

Please provide a full description of all activities undertaken by the Association:




Does the Association have any subsidiary organisations for which coverage is required?                   Yes/No

If Yes, please provide names, details of activities and turnover:




Please state the total number of:

Dwelling Units                                                 Directors and Officers
Shareholders                                                   Shares Issued
Shares held by Directors and Officers

Please list the names of all the Directors and Officers of the Association where different from the last Report
and Accounts:




Please state the number of full or part time staff that the Association employs:
Full time:
Part time:

Financial Information

Please provide the following financial information for the Association:
                                 Past Financial Year      Current Financial Year      Forthcoming Financial Year
Gross Assets                     £                        £                           £
Income/Turnover                  £                        £                           £
Shareholder Funds/Reserves £                              £                           £

Risk management

Are you responsible for arranging the buildings’ and/or property owners’ insurance for the               Yes/No
residential properties?

If Yes, is such insurance currently in force and will uninterrupted cover be maintained in the future?   Yes/No

Does the Association hold any of the residents monies and/or assets?                                     Yes/No

If Yes, please provide details:




                                                        3
Material Facts                                                   county court judgements, bankruptcy orders or
All material facts must be disclosed. Failure to do so           repossessions). Information may also be shared
could invalidate the policy. A material fact is one              with other insurers either directly or via those acting
which is likely to influence an insurer in the                   for the insurer (such as loss adjusters or
acceptance and assessment of the risk presentation.              investigators).
If you are in any doubt as to whether a fact is                  In the case of personal data, with limited exceptions,
material then it should be disclosed to the insurer. If          and on payment of the appropriate fee, you have the
any changes in circumstances arise during the                    right to access and if necessary rectify information
period of insurance cover please provide your                    held about you.
insurer with details.
                                                                 Credit Searches and Accounting
A specimen copy of the policy wording is available               In assessing your application the insurer may search
on request. We recommend you keep a record                       files made available to it by credit reference
(including copies of letters) of all information                 agencies who may keep a record of that search.
provided to the insurer for your future reference. A             The insurer may also pass to credit reference
copy of the completed proposal form will be supplied             agencies information it holds about you and your
on request within a period of three months after its             payment record. Credit reference agencies share
completion.                                                      information with other organisations, enabling
Disclosures should be clear and specific. The                    applications for financial products to be assessed or
insurer will not be deemed to have knowledge of any              to assist the tracing of debtors or to prevent fraud.
information generally referred to (for example the               The insurer may ask credit reference agencies to
contents of company websites listed in the proposal              provide a credit scoring computation. Credit scoring
form) or any matter not expressly drawn to our                   uses a number of factors to work out risks involved
attention.                                                       in any application. A score is given to each factor
Data Protection Act                                              and a total score obtained. Where automatic credit
For the purposes of the Data Protection Act 1998,                scoring computations are used by the insurer,
the Data Controller in relation to any personal data             acceptance or rejection of your application will not
you supply is Aviva Insurance Limited.                           depend only on the results of the credit scoring
Fraud Prevention and Detection                                   process.
In order to prevent and detect fraud we may at any               Sensitive Data
time share information about you with other                      In order to assess the terms of the insurance
organisations and public bodies including the Police.            contract or administer claims that arise, the insurer
Insurance Administration                                         may need to collect data that the Data Protection Act
The insurer, its associated companies and agents,                defines as sensitive (such as medical history or
reinsurers and your intermediary, may use                        criminal convictions). By proceeding with this
information you supply for the purposes of insurance             application you will signify your consent to such
administration. It may be disclosed to regulatory                information being processed by the insurer or its
bodies for the purposes of monitoring and/or                     agents.
enforcing the insurer’s compliance with any                      Marketing
regulatory rules/codes.                                          Aviva group and its agents may use your information
Your information may also be used for offering                   to keep you informed by post, telephone, e-mail or
renewal, research and statistical purposes and crime             other means about products and services which may
prevention. It may be transferred to any country,                be of interest to you. Your information may also be
including countries outside the European Economic                disclosed and used for these purposes after your
Area for any of these purposes and for systems                   policy has lapsed. If you do not wish your
administration. In assessing any claims made, the                information to be used for these purposes please
insurer or its agents may undertake checks against               write to Norwich Union, FREEPOST, Mailing
publicly available information (such as electoral roll,          Exclusion Team, PO Box 6412, Derby, DE1 1SB.

DECLARATION
You have read and checked the statements in the proposal form and agree its contents. You declare that the
information provided is, to the best of your knowledge and belief correct and complete. You agree that any
statements in the proposal form shall form the basis of the contract between the Insurer and you and if the
risk is accepted You undertake to pay the premium when called upon to do so. You understand that your
information may also be disclosed to regulatory bodies for the purposes of monitoring and/or enforcing the
Insurers compliance with any regulatory rules/codes.

Signed:                                                                           Date:

Position Held:


                                                             4
   Aviva Insurance Limited Registered in Scotland No 2116 Registered Office: Pitheavlis, Perth, Scotland, PH2 0NH
                  A member of the AVIVA Group. Authorised and regulated by the Financial Services Authority.

				
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posted:7/5/2011
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