Excess of Loss Quotation

Please read the following statements carefully and indicate acceptance below:

• Neither you or your directors or partners involved with your business or any other company or business have ever ;

• Been convicted of a criminal offence (other than a motoring offence) that is not spent under the Rehabilitation of Offenders Act 1974;

• Been declared bankrupt, insolvent, disqualified from being a company director or a Director or Partner with any company which went into receivership administration or liquidation within the last 10 years;

• Had an insurance proposal or cover declined, cancelled or refused;

• Been the subject of any County Court Judgements or Court Decrees within the last 10 years;

• Been subject to any HSE prohibition or improvement notice;

Confirmation that your activities do not include any of the following:

Work in or involving

• Height work in excess of 20m;

• Depth work in excess of 3m;

• Airlines, Aircraft, Aerodromes , airports or other aviation risks, aerial devices, drones or Unmanned Aerial Vehicle, spacecraft, launch sites or other space risks ( including refuelling , control tower liability and contractors carrying out construction, installation, servicing, maintenance or repair work within the perimeter of airports or aerodromes);

• Heavy construction involving bridges, tunnels, dams, cofferdams, towers, steeples chimney shafts, viaducts, main sewers, separate demolition contracts, work on underground storage tanks or the manufacture supply or erection of scaffolding;

• Mines, Quarries, Colleries, Dams, Chemical Works, Recycling Plants or Landfill Sites;

• Offshore Rigs and/ or Platforms and all other offshore work

• Railways, Trams, Buses or Cable Cars;

• Prospecting for or extraction of oil or gas, Oil and gas refineries or production plant, bulk Oil and gas storage facilities;

• Professional Sporting events, Racing events, amusement parks, fairs, circuses or carnivals;

• Public Utilities, Telecommunications Companies and Power generation operations;

• Ports, Port authorities, dry docks, docks, quays and wharves;

• Ship breaking yards and ships including construction, repair and installation work.

• Tankers, coaches, buses and/or the carriage of hazardous materials

The Operation of

• Hospitals, medical services, or care facilities;

• Sporting or entertainment venues with a capacity greater than 250;

The manufacture, repair, service, treatment, sale, supply, or distribution of, or products incorporated into:

• Automobiles, Trucks, Railways, Trams, Buses, Cable Cars, Motor Cycles or Bicycles;

• Aircraft, aerial device, drone or Unmanned Aerial Vehicle, Spacecraft, Hovercraft, Marine Vessels, diving or sky diving;

• Petro-chemicals, Chemicals, Pharmaceuticals, Herbicides, Pesticides;

• Medical Products, veterinary products or Animal Feeds;

• Cranes, hoists, lifts or elevators;

• The manufacture, production, distribution, supply, storage . Filling, packing, repacking, breaking down, installation ,removal or transport of Asbestos, Ammunition, Arms, Explosives or Fireworks, gases or air;

• The manufacture or wholesale of Tobacco or Tobacco Products or E-cigarettes or similar devices or liquids intended for use in e-cigarettes or similar devices or any substance intended for inhalation, or any device intended to facilitate inhalation

Please tick the box to confirm that the client can meet all of the criteria outlined above.

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If not then please give details below*:

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