Energy assessors, air conditioning and home inspectors
Proposal form
conditioning inspections and home condition reports.
This proposal form / In deciding whether to accept the insurance and in setting the terms and premium, we have relied on the information you have given us.
You must:
give a fair presentation of the risk to be insured by clearly disclosing all material facts
and circumstances (whether or not subject to a specific question) which you, yoursenior management and those responsible for arranging this insurance,know or ought to know following a reasonable search;
take care by ensuringthat all information provided is correct, accurate and complete.
Your details / 1. / a. / Name:
Address:
Postcode: / Telephone number:
Email:
b. / Total number of employees (full and part-time):
c. / What was your annual income for the last completed financial year? / £
(If you have not yet completed a full financial year, please provide an estimation of income)
2. / a. / Do you require cover for any activities other than energy assessment, air-conditioning inspection and home inspection? /
Yes No
b. / Which certification schemes do you work through?
3. / a / In the last five years has a claim or loss, whether successful or not, occurred or been made against you or your predecessors
in business, or any past or present partner, principal, director
or employee? /
Yes No
b. / Are you aware after reasonable enquiry of any matter which may lead to a claim against you? This includes, but is not limited to: /
Yes No
i. / a shortcoming in your work known to you which you cannot reasonably put right; /
Yes No
ii. / a complaint about your work or anything you have supplied which cannot be immediately resolved; /
Yes No
iii. / an escalating level of complaint on a particular project; / Yes No
iv. / a client withholding payment due to you after any complaint. / Yes No
c. / Are you aware of any loss from the dishonesty or malice of any employee or self-employed freelancer? /
Yes No
d. / Are you aware, after enquiry, of any potential disease or injury to an employee that may give rise to a claim? /
Yes No
e. / Have you ever had an insurance or proposal cancelled, withdrawn, declined or made subject to special terms? /
Yes No
If you have ticked any of the shaded boxes for questions 2a, 3a, 3b, 3c, 3d or 3e, please provide details in the material information section on page three.
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Energy assessors, air conditioning and home inspectors
Proposal form
Professional indemnity packages − please select level of cover required
Limit of indemnity
(any one claim,
costs in addition) / Dwelling energy
assessment only / Air conditioning inspections, homecondition reports, dwelling and non-dwelling energy assessment
£100,000 / £295 / £443
£250,000 / £407 / £611
£500,000 / £555 / £832
£1,000,000 / £713 / £1,069
£2,000,000 / £1,222 / £1,578
The following optional covers are available:
Covers / Limit of indemnity / Package total / Tick if
required
Public liability / £1,000,000 / £71
Employers’ liability / £10,000,000
Public liability / £2,000,000 / £102
Employers’ liability / £10,000,000
Portable computer and
electrical equipment / £1,000 / £51
Period of insurance
The premiums stated above represent premiums due for the first 12 months of a continuous policy of insurance. This is not an annual policy.
Retroactive cover
If you currently purchase professional indemnity cover, please provide
the date when you first purchased cover without any gaps in insurance
//
Excess / Energy performance certificates: / £500 each and every loss excluding defence costs
Home condition reports and air conditioning inspections / £2,500 each and every loss excluding defence costs
Employers’ liability / Nil
Public liability / £250 each and every claim(only in respect of property damage)
Portable computer and electrical equipment / £250 each and every claim
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.
Insurance details / Important notice for your protection
Within 30 days of receipt of this proposal acceptance form by us, you will be sent your policy documents which contain full details of your cover and other important information. Please take time to read these documents carefully, particularly noting the policy exclusions and limitations.
Please ensure that the details in the policy documents are correct.
In the event that you change your mind you have 14 days to cancel the policy and, providing that no claims have been made, receive a full refund. After that period you can cancel your policy by giving 30 days’ notice.
Acceptance / I would like to proceed with cover to start on* / //
*Please note that you can choose for cover to commence on any date within 30 days from when you sign this form. The commencement date cannot be in the past. Your application will be rejected if you choose
a commencement date in the past or more than 30 days in the future.
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.
If any material information is not disclosed we will be entitled to treat the insurance as if it had never existed.
If you have ticked any of the shaded boxes for questions 2a, 3a, 3b, 3c, 3d or 3e, please provide details here.
Is there anything else that you would like to tell us about you or your business? / Yes No
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7360 05/17
Energy assessors, air conditioning and home inspectors
Proposal form
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 1998. 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.
Payment by Direct Debit / If you wish to pay by direct debit please complete the Hiscox Direct Debit Mandate attached
to this form. We shall submit this form to your bank for authorisation and seek to withdraw
the premium due in accordance with your direct debit mandate instructions. If it is rejected
we shall submit it again. If the direct debit mandate is rejected a second time we shall give
you notice of our intention to cancel the insurance policy or shall contact you in order to
agree an alternative source of payment.
Declaration / I/we confirm that the information given in this proposal form is correct, accurate and complete and I have made a fair presentation of the risk.
Name of director/officer/board member/senior manager
//
Signature of director/officer/board member/senior manager / Date
A copy of this proposal should be retained for your records.
Please return this form to your broker once it has been completed
Complaints / Our aim is to ensure that all aspects of your insurance are dealt with promptly, efficiently and fairly. At all times we are committed to providing you with the highest standard of service. If you have any questions or concerns about your policy or the handling of a claim you should,
in the first instance contact your broker:
If your broker cannot resolve your complaint satisfactorily, please contact our customer relations team in writing at:
Hiscox Customer Relations
The Hiscox Building
Peasholme Green
York YO1 7PR
by telephone on 0800 116 4627/01904 681 198
or by email at .
If you are dissatisfied with the way Hiscox Customer Relations handle your complaint you may be eligible to refer your complaint to the Financial Ombudsman Service. Further details will be provided at the appropriate stage of the complaints process. This complaint procedure is without prejudice to your right to take legal proceedings.
PF-PIP-UK-DEA(4) Hiscox Underwriting Ltd is authorised and regulated by the Financial Conduct Authority.
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