Management Liability Portfolio Proposal Form - Willis

6131 04/09
Management Liability Portfolio
Proposal form
Your cover Directors and officers’ liability, employment practices liability and corporate legal liability
Limit (aggregate
/costs inclusive)
Per section
Up to €2.5m €2.5m to
€10m
Turnover
€10m to
€25m
€500,000 €1,000 €1,300 €1,600 €2,000
€1,000,000 €1,500 €1,800 €2,100 €2,500
€2,500,000 €2,300 €2,600 €2,900 €3,300
€5,000,000 €4,500 €4,800 €5,100 €5,500
€25m to
€50m
The premiums shown include Insurance Levy of 3% and apply only if you have not ticked any
of the shaded boxes on page 1. The premiums stated above represent premiums due for the
first 12 months of a continuous policy of insurance. This is not an annual policy.
Excess Directors and officers’ liability: € Nil
Employment practices liability:
€10,000 each and every loss including defence costs
Corporate legal liability €2,500 each and every loss including defence costs
Please enter the date you would like the policy to start:
Cover will only commence upon confirmation from Hiscox.
Please note that this insurance policy is a continuous insurance policy and that it will
therefore continue in force until either party gives notice of termination in accordance
with the procedure set out in the terms or until Hiscox terminates the policy following
the non-payment of any premium due from you.
Material information Please provide us with details of any information which may be relevant to our consideration of
your proposal for insurance. If you have any doubt over whether something is relevant, please
let us have details.
Data Protection Act By signing this proposal form you consent to Hiscox using the information we may hold about
you for the purpose of providing insurance and handling claims, if any, and to process sensitive
personal data about you where this is necessary (for example health information or criminal
convictions). This may mean we have to give some details to third parties involved in providing
insurance cover. These may include insurance carriers, third-party claims adjusters, fraud
detection and prevention services, reinsurance companies and insurance regulatory
authorities. Where such sensitive personal information relates to anyone other than you, you
must obtain the explicit consent of the person to whom the information relates both to the
disclosure of such information to us and its use by us as set out above. The information
provided will be treated in confidence and in compliance with the Data Protection Act 1988.
You have the right to apply for a copy of your information (for which we may charge a small
fee) and to have any inaccuracies corrected.