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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]