Eventualities – Insurance for Events - Canoe England

Eventualities – Insurancefor EventsProposal Form

IMPORTANT INFORMATIONYour insurance contract will be prepared based on the information supplied by you, which is shown on this Proposal. To the best of your knowledgeand belief, you must be satisfied the information is correct.It is important that you let us know about anything that could influence the insurers attitude to your proposal.PLEASE COMPLETE CLEARLY IN BLOCK CAPITALSGeneral Questions (to be completed by the Proposer)The Insured1 Name/Organisation:2 Address:Postcode:Telephone No:Fax No:3 E-mail address:The Event4 Name of Event:a) Full description including associated activities, sideshows etc. (attach a brochure if available)b) Period at Venue From Toc) Event Open Dates From Tod) Estimated attendancee) Estimated Gross RevenueThe Venue (where principal activities to be held)5 Name:6 Address:PostcodeEvent History(please tick)7 Has Event been held before? Yes Noa) If YES, for how many years? yearsb) Previous location and dates?a)b)8 Have there been any losses, incidents or claims at any previous Event that would have been covered by this policy? Yes No9 Has any Insurer declined to insure, cancelled or refused renewal or imposed special terms in respect of this or anyprevious Event? Yes NoIf YES please provide details

1. Public and Products Liability10 Do you require cover under this Section? Yes No11 Limit of liability required?£2,000,000 £5,000,00012 Does the Event include hazardous activities, such as fairground and amusement rides, bouncy castles, motorised,waterborne or aerial activities or fireworks? Yes NoIf YES, will such hazardous activities be provided, managed and supervised by Bona Fide Sub-Contractors with their ownPublic Liability insurance? Yes No(N.B. you must check that Bona Fide Sub-Contractors have Public Liability Insurance in force and for hazardous activities you must retaindocumentary evidence, otherwise cover is excluded)2. Employers Liability (only available with Section 1)13 Do you require cover under this Section? Yes No14 Please state the number of employees, casual workers, helpers and volunteers(N.B. Helpers and volunteers are deemed to be employees and are excluded from cover under the Public and Products Liability Section)3. All Risks (The maximum Sum Insured under this Section is £50,000)15 Do you require cover under this Section? Yes NoIf YES please state replacement value of all property used in connection with the event, including, but not limited, toa) Display stands, furnishings and fittingsb) Marquees, tents and other temporary structuresc) Audio visual equipmentd) Portable communication equipmente) Portable toiletsf) Stockg) Other (please specify)£££££££(N.B. Wines, Spirits, cigarettes and tobacco limited to a maximum of £500)4. Money (only available with Section 3)16 Do you require cover under this Section? Yes No17 Please state the maximum amount at risk?£(N.B. maximum Limit of Liability under this Section is £5,000 any one loss and a £2,000 Personal Carrying Limit (money any one person)also applies)5. Cancellation (The maximum Sum Insured under this Section is £50,000)18 Do you require cover under this Section? Yes NoPlease state the sum to be insured in respect of:19 Costs and Expenses20 Net Profit££(N.B. evidence of such sum insured will be required from previous years records of the Event)21 Is the Event to be held wholly in:a) a building? Yes Nob) the open? Yes Noc) temporary structure? Yes Nod) or a combination of above? Yes Noe) If YES to d), please detail which and extent of each22 Please provide full details of temporary structures

23 What are the most likely reasons for the Event not taking place?24 Have all necessary contractual arrangements been made and all authorisations obtained? Yes NoIf NO, please provide full details6. Non-Appearance (only available with Section 5)25 Do you require cover under this Section? Yes No26 Please specify Persons for whom cover is requiredName(s) Age(s) Role at Event Are they in good health?YesYesYesNoNoNoPOLICY COMMENCEMENT DATE/ /NB: We recommend cover should commence at the time of organisation and payment of deposits. Coverage under Sections E and F,Cancellation and Non-Appearance, is not available unless purchased 14 days prior to Event Open Date.NO INSURANCE IS IN FORCE UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AND FULL PREMIUM HAS BEEN RECEIVEDPersonal DataYou have the right to access any records about you, which we hold on computer files under the Data Protection Act 1984. Insurers and their agentsshare information with each other to prevent fraudulent claims and to assess whether to offer the insurance including the terms via the Claims andUnderwriting Exchange Register, operated by Insurance Database Services Ltd. A list of participants is available on request. In dealing with yourapplication this register may be searched. In the event of a claim, the information you supply on this form and the claim form, together with otherinformation relating to the claim will be put on the register and made available to participantsTo set up and administer your policy Towergate Underwriting Group Limited will hold and use information about you supplied by you. They may send itin confidence for processing to other companies acting on their instructions including those located outside the European Economic Area. TowergateUnderwriting Group Limited may also send you details of their other products and services.Please tick this box if you do not wish to receive such details.Insurance Premium TaxThe Finance Act 1994 requires us to levy Insurance Premium Tax at the prevailing rate on insurance business. For further information, please askyour adviser.DeclarationTo the best of my knowledge and belief the information and statements provided in connection with this proposal, whether in my own hand or not,are true and complete and no material facts or information have been withheld or suppressed. I understand that non-disclosure or misrepresentationof a material fact may entitle insurers to void the insurance. (N.B. a material fact is one likely to influence acceptance or assessment of the risk byinsurers. If you are in any doubt as to whether a fact is material or not, please disclose it). I understand that signing this declaration does not bind meto complete, or insurers to accept, this insurance. I understand and agree that insurers may seek information from credit and other agencies inconnection with this proposal.Signature(s)DateTowergate Underwriting Entertainment77 Leadenhall Street, London, EC3A 3DETel: 0870 909 2575 Fax: 0870 909 2576Email: entertainment@towergate.co.uk www.towergateentertainment.co.ukTowergate Underwriting Entertainment is a trading name of Towergate Underwriting Group LimitedRegistered Office: 2 County Gate, Staceys Street,Maidstone, Kent, ME14 1STRegistered in England No. 4043759Authorised and regulated by the Financial Services Authority1107/85/PF/05.06/3453