Bespoke Cover Insurance Proposal Form

A tailored policy for members with more in-depth requirements than simple PPL cover.

Please enter your full details

Title*

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Your Name*

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Trading or Company Name (if applicable)

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Address*

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Mobile/Telephone Number*

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Email*

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Website Address

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Legal Status*

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GoJD Membership Number

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Membership Level

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Please give a brief description of your business including details of materials and processes you commonly use:*

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Year Started*

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Current Insurer

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Renewal Premium Amount

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Date to start insurance*

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Date insurance ends (dates inclusive)*

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Cover Required Section 1 - Work and Materials

Is cover required for work and materials?* No Yes

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What is the maximum value of finished work, work in progess and materials in your premises at any one time? (Excluding specified materials below - see hint above.)

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What is the maximum value of finished work, work in progress and materials in your premises at any one time including precious metals, precious stones and jewellery?

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Maximum value of any single item of work?

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Do you want to extend cover to insure work and materials away from your premises (inc. whist in transit and at exhibitions worldwide)?*

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If yes, what is the maximum value of work and materials away from your premises at any one time?

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Section 2 - Tools, Equipment and Other Property UK, Europe and Worldwide

Is cover required for Tools, Equipment and Other Property?* No Yes

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Address of Studio Premises - See hint*

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Computer Equipment Cover Value Required?*

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Tools, Equipment and all Other Contents Value?

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Goods Held in Trust Value? (Excluding precious metals, precious stones and jewellery) See hint

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Goods Held in Trust Value? (Including precious metals, precious stones and jewellery) See hint

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Studio Buildings Value? - See hint

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Studio Improvements value? (See hint)

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Portable Property Values Used Away From Your Studio

(A) Tools and Equipment UK/Europe Sum Assured

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(B) Tools and Equipment Worldwide Sum Assured

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(A) Portable Computer Equipment Value UK/Europe Sum Assured

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(B) Portable Computer Equipment Value Worlwide Sum Assured

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(A) Any Other Property Value? UK/Europe Sum Assured (See hint)

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(B) Any Other Property Value? UK/Europe Sum Assured (See hint)

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Business Interruption

Do you require the annual gross profit cover increased from £50,000? (See hint)* No Yes

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Figure to increase to?

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Increase Accounts Receivable figure from £5,000 - See hint* No Yes

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Figure to increase to?

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Employers', Public and Products Liability

Employers Liability (See hint)* No Yes

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Public/Products Liability*

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No. of Proprietors/Business Partners teaching, preparing and display of work excluding use of applied heat away from own premises, including open studios, open houses and exhibitions?*

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No. of Proprietors/Business Partners teaching, preparing and display of work including use of applied heat away from own premises, including open studios, open houses and exhibitions?*

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No. of Proprietors/Business Partners using fixed woodworking or metalworking machines?*

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No. of Directors and Permanent Employees (Inc Freelance Workers) teaching, preparing and display of static art excluding use of applied heat away from own premises, including open studios, open houses and exhibitions?*

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No. of Directors and Permanent Employees (Inc Freelance Workers) teaching, preparing and display of static art including use of applied heat away from own premises, including open studios, open houses and exhibitions?*

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No. of Directors and Permanent Employees (Inc Freelance Workers) using fixed woodworking or metalworking machines?*

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Do you engage employees or freelancers on a temporary basis? - See hint*

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If yes, please indicate the estimated total number of days worked per year. - See hint Up to 50 days/year Between 51 and 100 days/year More than 100 days/year

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Estimated Employment Costs

Clerical, Managerial and Non-Manual Workers*

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Manual Workers (Inc Freelancers) on own premises?*

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Employees using fixed wood or metalworking machines on own premises?*

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Manual workers (Inc freelancers) away from own premises? Category 1*

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Manual workers (Inc freelancers) away from own premises? Category 2*

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Manual workers (Inc freelancers) away from own premises? Category 3*

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Manual workers (Inc freelancers) away from own premises? Category 4*

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Estimated Turnover

Estimated Turnover (excluding turnover derived from activities in or work supplied to the USA or Canada)*

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Estimated Turnover derived from activities in or work supplied to the USA or Canada*

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Information About Your Studio Premises

in a good state of repair?* Yes No

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constructed with more than 10% combustible materials?* No Yes

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heated using portable paraffin or gas heaters?* Yes No

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flat roofed with felt on timber comprising more than 25% of the roof area?* Yes No

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fitted with key operated locks to all accessible windows?* Yes No

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ever been affected by subsidence, heave or groundslip?* No Yes

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self contained with their own lockable entrance?* Yes No

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have (BS3621) 5 lever mortise dead lock on all entrances and exits?* Yes No

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in an area prone to flooding?* No Yes

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protected by an intruder alarm system* Yes No

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If protected by an alarm, is the alarm maintained by a company approved by either N.S.I or S.S.A.I.B.?* Yes No

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If protected by an alarm, is it linked to a security company receiving centre or the police?* Yes No

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If alarm is linked to security company, please state method of signalling (eg. Redcare)

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Additional Information - See hint

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Information About Your Artistic Practice

Use heat equipment on 3rd party premises? See hint* Yes No

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Use heat equipment on your own premises? See hint* Yes No

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Undertake any work at heights over 10metres above ground level (or floor level in the case of work inside a building or structure)?* Yes No

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Undertake work at any power stations, nuclear installations or establishments, refineries, premises connected to the oil, gas or chemical industries, aerospace systems or watercrafts, railways, airports, underground or underwater?* Yes No

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Undertake work in the United States of America or Canada?* Yes No

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Supply work to the United States of America or Canada?* Yes No

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Do you engage bona fide sub-contractors with own insurance?* Yes No

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Use, handle, store or transport any hazardous substance? - See hint* Yes No

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Additional Information regarding your artistic practice - See hint

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Previous Claims/LossHistory

Add details here, dates, details amount claimed and if settled.

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General Disclosure and Material Information

Ever had an insurance declined, cancelled or renewal refused or had special terms, restrictions or conditions imposed by an insurer?* No Yes

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Been prosecuted, or have any prosecution pending, under the Health and Safety at Work Act or any similar legislation?* No Yes

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Been declared bankrupt or been disqualified from being a company director?* No Yes

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Been involved as an owner, director or partner of any company that went into receivership, administration or liquidation?* No Yes

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Been the subject of (or have pending) any County Court Judgements?* No Yes

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Been convicted, or charged (but not yet tried) in respect of any criminal offence?* No Yes

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Additional Information and Material Facts to be disclosed to underwriters - See hint

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I/We declare that to the best of my/our knowledge or belief, the particulars and statements given in this document and any additional information provided to Hencilla Canworth are true and complete.

Full name:*

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Date*

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Cart Summary

Bespoke Insurance Form

Bespoke Cover Insurance Proposal Form

A tailored policy for members with more in-depth requirements than simple PPL cover.

Please enter your full details

Cover Required Section 1 - Work and Materials

Section 2 - Tools, Equipment and Other Property UK, Europe and Worldwide

Portable Property Values Used Away From Your Studio

Business Interruption

Employers', Public and Products Liability

Estimated Employment Costs

Estimated Turnover

Information About Your Studio Premises

Information About Your Artistic Practice

Previous Claims/LossHistory

General Disclosure and Material Information

I/We declare that to the best of my/our knowledge or belief, the particulars and statements given in this document and any additional information provided to Hencilla Canworth are true and complete.

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