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Headley Insurance Services Ltd
Garden Design Insurance Proposal Form
Name:
___________________________________________________________
Address:
___________________________________________________________
___________________________________________________________
Post Code ____________________
Telephone No: ____________________________ Fax Number: __________________
Email Address: ___________________________
Date Business Established
Web Site Address: _____________
__________________ Business Description: ___________
Please provide details of Fee Income:
Coming Year:
£ _____________________ Last Year £ ___________________
Please provide split between:
Consultation Advice, Appraisal Work and Concept design work : _____________%
Project Management, Structure Design ie: walls, outbuildings,
paths, walkways, water features, sculptures and rock gardens:
_____________%
Maintenance & Planting Work to include mowing:
_____________%
Constructional Work i.e: hard landscaping and tree planting:
_____________%
Please indicate below if you require quotations for:
Professional Indemnity
Yes / No
Limit of Indemnity Required: £100,000,
£250,000, £500,000
(delete as appropriate)
Level of Excess Required:
£500
£1,000
(delete as appropriate)
£250
Do you have cover in place at present?
Yes / No
(delete as appropriate)
£1 million
(delete as appropriate)
Name of insurer: ___________________________ Renewal date: _________________
Premium Paid: £ ________________________
Public Liability
Yes / No
(delete as appropriate)
Limit of Indemnity required: £1 million
£2 million
£5 million
(delete as appropriate)
Number of Principals:
________________________
Employers Liability
Yes / No
(delete as appropriate)
Number of Full Time Staff Employed
Number of Part Time Staff Employed
Wageroll
Wageroll
Manual / non manual*_______________
Manual / non Manual*_______________
Manual
£______________
Non Manual*
£______________
* Non Manual means consultative, design, appraisal, project management and maintenance
Do you employ Temporary Staff? e.g: seasonally
Yes / No (delete as appropriate)
General Questions
1.
Do you undertake work outside the United Kingdom?
Yes / No
If so please provide details on separate sheet of type of work and value.
2.
My largest contract undertaken is £ _________.
If greater than £5,000 please provide specific details on separate sheet.
3.
Have you suffered any losses or made any claims in respect
of the above three types of insurances?
Yes / No
(If yes then please provide details on separate sheet.)
Please provide a copy of your curriculum vitae and company brochure if available.
Please read the following DECLARATION as it will form the basis of the insurance
contract.
I/we declare to the best of our knowledge and belief the answers given are true and
complete.
I/we declare that the information provided in this proposal from and any other information
supplied by me/us shall be incorporated in and form part of the insurance contract.
I/we declare that we are unaware of any claims that may be made or have been made
against me/us.
Signature _________________________________ Date _______________________
Please return to: Headley Insurance Services Ltd, William Curtis House, Lenten
Street, Alton, Hants, GU34 1HH
Telephone Number: 01420 594242 Fax Number: 01420 594230
Email: [email protected]