Directors' & Officers' Proposal Form
To arrange cover complete the form below, print and then sign it and post FREEPOST to Holland Insurance Brokers FREEPOST ANG2312 CLACTON ON SEA Essex CO15 5YY
Name of Company
Address of Company
Address of block if different
Contact Name
Phone Number
Date of Incorporation
Income of Company
Limit of indemnity required £100,000 or Other
Total number of Flats: how many blocks
Is the Company Private Public Registered Charity Limited
Is the building and the land upon which it stands owned (as to the freehold) by The Proposers Company A Third Party
Names of directors where different from Accounts
1.Have there been any disputes with the Freeholder Yes or No
2.Have any Lessees declined to become members of the Company Yes or No
3.Have there been any incidents or claims in the last 10 years that would have been covered by insurance similar to that for which you are now applying Yes or No
4.Are you aware of any circumstances that might give rise to a claim Yes or No
5.Have the Proposers any other Directors' & Officers' Insurance in force Yes or No
6.Have any insurers declined, refused to renew or imposed punitive terms on any of the Proposers insurances Yes or No
7.Does the Proposer have any subsidiary companies Yes or No
8.Are all the services carried out through a managing agent Yes or No
9.Are the Proposers aware of any circumstances which might affect the insurers consideration of this insurance Yes or No
10.Does the company carry out any other functions other than the management of the property detailed above Yes or No
If any of the answers to questions 1 -10 are yes please provide full details below
1. Before signing the declaration below please ensure that all questions have been answered. You are reminded that you must disclose all material facts likely to influence the acceptance and assessment of this proposal. Failure to do so may render the insurance voidable. If there is any doubt whether a facts might be considered material these should be disclosed. no insurance is in force until the proposal has been accepted by the company. The Company reserves the right to decline any proposal. 2. Insurers and their agents share information with each other to prevent fraudulent claims and for underwriting purposes via the Claims and Underwriting Exchange Register, operated by Insurance Database Services Ltd. A list of participants is available on request. In dealing with your application this register may be searched. In the event of a claim, the information you supply on this form and the claim form, together with other information relating to the claim, will be put on the register and made available to participants. Declaration:I declare (a) on behalf of the company (b) for myself and after enquiry of and with the express consent of each of the Directors named in this proposal (1) that the above statements are true and complete (2) that the proposers agree that this proposal shall be incorporated in the contract between them and the insurer (3) that the Proposers agree to accept a policy in the insurer's usual form for this class of insurance. (4) I undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance.
Signed: Title: Date:
Chairman or Chief exec of the Co. on behalf of the Proposers / (signing this form does not bind the Proposers to complete)
I enclose my cheque for £ Payable to Holland Insurance Brokers
Alternatively please debit my card No. Expiry
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