Access Client Form

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1Basic Details

2Activities

3Profile

4Cover

5Declarations

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How did you find out about us?*

How did you find out about us? Other details*

Privacy and Accessibility

Privacy Statement Acceptance*

I accept

Any data we collect, including any personal and sensitive data, will only be information necessary solely to provide a quotation and policy. We will share your data with insurers and other bodies involved, for the purpose of arranging and administering your insurance. If you cannot provide all of the information requested, we will be unable to quote or offer cover. We never share your data with anyone outside our organisation for any marketing purpose.

Do you have any special requirements in the way we deliver our service to you?*

Yes

e.g. accessibility requirements such as large print.

If yes, what special requirements do you have, that will help our team deliver our service to you?*

Provide details of special requirements.

Contact Details

Your Name*

First Last

Email Address*

Telephone Number*

Organisation Details

Name of Organisation*

Full legal name, needs to match your constitution so the contract of insurance is valid

Organisation Legal Status (Select as many as apply)*

Voluntary Group / Non Profit Group

Registered Charity

CIO – Charitable Incorporated Organsiation

CIC – Community Interest Company

Social Enterprise (Ltd Company)

Company Ltd by Guarantee

Limited Company (for profit)

Individual or Sole Trader

Other

Sorry, we cannot insure individuals. Our insurance products are designed specifically for constituted groups or charitable/not-for-profit organisations. (If you are running a charitable organistation such as an After School Club as a sole trader, then please continue.)

Please describe the organisational legal status*

Registered Charity Number*

Registered FCA Number*

Registered Company Number*

Does your charity have a constitution/governing document?*

Yes

No, but we intend to sort one before buying insurance.

We can provide a quote for your group, however, to enter into an insurance contract your group will need to have a constitution or another type of governing document. You can read more about constitutions and view a sample here. If you don’t intend to proceed with a constitution then we cannot give you a quote.

To enter into an insurance contract your group will need to have a constitution or another type of governing document. You can read more about constitutions and view a sample here. If you don’t intend to proceed with a constitution then we cannot give you a quote.

Year Established*

Does the group have any subsidiaries?*

Yes

Name of Subsidiary*

Full legal name, needs to match your constitution so the contract of insurance is valid

General details of subsidiary*

How many subsidiaries are there? Are they Profit / non-profit? | Are they wholly owned by your group? | Do they have the same aims and activities? | Do they have the same management committee?

Subsidiary – Organisation Status*

Registered Charity

CIO – Charitable Incorporated Organsiation

CIC – Community Interest Company

Social Enterprise (Ltd Company)

Company Ltd by Guarantee

Limited Company

Other

Please select the option that best describes the subsidiary status.

Subsidiary – Registered Charity Number*

Subsidiary – Registered FCA Number*

Subsidiary – Registered Company Number*

Are you registered with any regulatory bodies?*

Yes

Which regulatory bodies are you registered with?*

None of the below

Care Quality Commission

Ofsted

The Fundraising Regulator

Healthcare Regulators (e.g GMC)

Regulator of Social Housing

Financial Conduct Authority

The Gambling Commission

Other

Which other regulatory authorities are you registered with?*

Is the organisation currently insured?*

Yes

Your Renewal Date*

DD dash MM dash YYYY

Your Current Insurer*

Long Term Agreement*

Yes

Are you currently in a long term agreement?

When Would You Like Cover to Commence?*

DD dash MM dash YYYY

Location and Website

Website Address

Main Location Address*

Postcode

9VZ2-JSWC-S4HE-3RNU

DaviDoyle882157

Select an Address:

Address Line 1 Address Line 2 Address Line 3 Address Line 4

Is this address also the correspondence address?*

Yes

Correspondence Address*

Postcode

9VZ2-JSWC-S4HE-3RNU

DaviDoyle882157

Select an Address:

Address Line 1 Address Line 2 City County

Your Goals and Activities

Thank you for providing these details. Can you tell me about your organisation and your activities?

Please describe the aims & activities of your organisation*

Subsidiary – Please describe, as fully as possible, the current and future activities of the subsidiary*

Do your activities include:*

None of the below

The use, sale or supply of alcohol

Power tools, powered machinery or similar?

The sale, repair or supply of goods

Work at height (generally over 3 metres)

The use of bonfires

Fireworks/pyrotechnics

Any overseas activities

Work with animals

Residential stays

Catering

Personal care

Adventure activities (e.g. climbing)

Bouncy castles or other inflatables

Contact sports

Water-based activities

Motorised vehicles

Please describe the activities involving alcohol*

Where and how is alcohol provided? If so – Are staff or volunteers trained to refuse service to underage or intoxicated individuals? | How many alcohol related events do you run each year? | Is there a written policy for managing alcohol related risk

Do you have a bar at your premises?*

Yes, it is our own premises

Yes but it is a third party premises

Do you have a temporary or permanent liquor licence?*

Permanent Liquor Licence

Temporary Liquor Licence

No Licence

What time does your bar serve until? (at any occassion)*

Do you have either of the following?*

Door security (at any events)

A dance floor

Please describe the activities involving contact sports*

Please provide an overview of your sports activities, including the sports played.

Do you play in a league structure?*

Yes

Do any activities include boxing, martial arts or similar?*

Yes

Please describe the activities involving adventure activities*

Please provide as many details as possible including: Activities and who they are for (members/public), participants (age, experience, typical numbers), locations and environments used, supervision and instructor qualifications, key safety and risk management procedures, emergency and first aid arrangements

Are your adventure activities undertaken at your own premises?*

At our own venue

At a separately insured third party venue

Please describe the nature of your residential activities*

Please describe your residential activities as fully as possible including where they take place, who goes, the activities included and whether children or vulnerable adults attend

Are your residential activities:*

Permanent residential activities

Occassional trips

Both of the above

Do you have risk assessments specifically for the residential activities?*

Yes

Please provide details of the tools and machinery that your activities involve and the items that you produce or repair.*

Do you only use hand tools?*

Yes

Please describe the hand tools in use

Do you use machinery or powered tools?*

Yes

Please provide a list of the powered tools and machinery in use:*

Do you use any hot tools?*

Yes

such as hot lances, welding equipment, kilns or soldering irons

Are tools checked to make sure they are fit for purpose?*

Yes

Do you have a manual handling policy in place?*

Yes

Are inexperienced volunteers ever left unsupervised?*

Yes

Do any members under the age of 18 use the powered tools or equipment?*

Yes

Are all volunteers and staff receive training to use equipment safely?*

Yes

Are your activities involving tools and machinery risk assessed?*

Yes

Are automatic cut off devices fitted to equipment where necessary?*

Yes

Is correct PPE in use?*

Yes

Is there a maintenance programme for all machinery and are manufacturers recommendations followed through?*

Yes

Are areas of work kept cleared of debris?*

Yes

Is supervision provided where necessary?*

Yes

Are qualifications/competence for using machinery in place?*

Yes

Please provide details of work 'at height'*

Please give a general description of your work at height

What is the maximum height or depth you would work at?*

Do your employees and volunteers working at height have adequate training and qualifications?*

Yes

Do you have specific risk assessments and a ladders policy?*

Risk Assessments

Ladders / Height policy

Both

Neither

Which of the following would you use?*

Ladders

Manual platforms

Powered platforms

Cables or ropes

Scaffolding

None of the above

Will the bonfire be fully extinguished at the end of the event*

Please provide an overview of the nature of the bonfire, how large it will be and what materials will be burned

How many people attend the bonfire event?*

Is the bonfire cordoned off from the public?*

Yes

Will sparklers be used by attendees at the bonfire?*

Yes

Will Chinese lanterns (or similar) be used by attendees at the bonfire?*

Yes

Do you have a specific risk assessment for the bonfire?*

Yes

Do you use any accelerants to help light the fire?*

Yes

Do you have fire extinguishers on hand*

Yes

How will your activities specifically involve fireworks/pyrotechnics?*

We fire them

Fired by a separately insured third party

Please provide an overview of the fireworks event*

A general description of the event

How many people will attend your fireworks event?*

Will the fireworks be cordoned off from the public?*

Yes

Do you have a specific risk assessment for the fireworks event??*

Yes

Do you comply with HSE guidance on firework displays and storing and selling fireworks*

Yes

Can you confirm only fireworks labelled as Categories 1 2 or 3 under the Pyrotechnic Articles Safety Regulations 2010 will be used*

Yes

Do first aiders attend the event?*

Yes

Please describe your overseas activities*

Please describe in general your overseas activity including any duration of trips and number of travellers and how many trips per annum you undertake. Please also indicate the nature of these trips and the activities you will undertake.

Are trips organised by you or a third party tour operator?*

We organise the trips

We use a third party to organise the trips

Are there any non UK nationals requiring cover ?*

We organise the trips

We use a third party to organise the trips

Will travel insurance be arranged by you or by individuals?*

Yes

Please provide a list of the countries that you visit*

Will you visit any countries against Foreign Office advice?*

Yes

Please describe in general your activities involving animals*

Please indicate which animals you work with and add any not on the list*

Dogs

Cats

Small Mammals (e.g. Rabbits, guinea pigs)

Cattle

Sheep or Goats

Pigs

Poultry

Horses or Ponies (ridden)

Horses or Ponies (never ridden)

Reptiles (snakes / lizards)

Amphibians (frogs / salamanders)

Birds

Fish

Other

Please add any animals that you work with not listed above*

Do you work with any dogs listed under the Dangerous Dogs Act*

Yes

Will you place any animals into foster care?*

Yes

Foster care is when an animal is placed with a volunteer/employee until the animal can be rehomed.

Do you have formal vetting and procedures in place concerning the fostering of animals?*

Yes

Is any medication or treatment administered (including microchipping)??*

Yes

How many paid or unpaid foster volunteers do you have?*

Do you provide formal training for volunteers working with animals?*

Yes

Please detail any catering activities*

Please give a general description of your catering activities.

Where do you prepare food?*

A premises we are responsible for

A third party premises

Is there any use of deep fat fryers?*

Yes

Are those handling food trained in food hygiene and food safety*

Trained and Qualified

Trained

Neither Trained or Qualified

Do you have written food hygiene procedures?*

Yes

Please detail any personal care or treatment*

Do you provide any medical advice or services

Please describe the nature of the service users that are recipients of the personal care you provide*

Do you provide domicillary care?*

Yes

Do you administer medication?*

Yes

Do you provide any overnight residential care?*

Yes

Do you use specialist equipment or machinery?*

Yes

e.g. hoists

Are staff trained and qualified for the care or treatment provided?*

Yes

Do you provide any medical advice or services?*

Yes

Are you registered with the Care Quality Commission?*

Yes

Please detail any water-based activities*

Please provide a general description of the water-based activities undertaken including the type of craft or sport and whether participation is for members only or the general public

Where do your water based activities take place?*

Swimming Pools

Rivers, lakes, canals inland waterways

Coastal (within three miles of the coast)

Open sea activities

Select all that apply

Do you use water craft that are either mechnically propelled or over 9 metres in length?*

Yes

Boats, jet skis etc

Do you have risk assessments to cover the activities on water?*

Yes

Boats, jet skis etc

Please detail any motorised vehicles*

Please give an overview of the activities including motorised vehicles including if they are separately insured

The sale, supply or repair of goods*

Please describe the work you do in respect of the manufacture, sale or repair of any goods. Please include details of the experience of the people undertaking this activity and the items you work upon.

Do any items fall into higher-risk categories such as white goods, electrical appliances, pressurised systems or refrigeration equipment?*

Yes

Are any repairs on 'safety critical' equipment?*

Yes

e.g. medical equipment, structural work, fire alarms, electrical systems or any work or on any equipment that could cause injury if it fails

Do you conduct PAT Testing?*

Yes

Yes, by qualified volunteers or staff

Do you work on new or second hand items?*

New

Second Hand

Both

Will work all take place at your premises or will any of it be undertaken away from your premises?*

Only at our premises

Some work away from our premises

Are your inflatables:*

Hired in

Owned by the group

Details of inflatables usage*

Please describe the number and types of inflatable, their age and condition.

Do you supervise the use of the inflatables?*

Yes

Do you use inflatable equipment outdoors?*

Yes

Do you have a risk assessment for these activities?*

Yes

Do you hire your inflatable equipment to third parties?*

Yes

Is your equipment regularly maintained and inspected?*

Yes

Does your equipment have a current PIPA certificate in line with the manufacturers recommendations?*

Yes

Unsure

Advice and Events

Do you provide advice as part of your activities?*

Yes

Not sure

Details of advice provided*

(What advice is provided, how often and what qualification and experience do advice givers have.

Are you planning any events?*

Yes

Do your events include any of the following:*

None of the Below

Fairground Rides

Inflattables

Parades

Motorised Vehicles

Animal Shows

Bonfires

Fireworks

Select all that apply

Please describe the events that you are planning to run*

Please include the maximum attendance at any event and a description of the types of events you are planning. Where are the events held?

What will be the maximum total attendance at a single event?*

How many events will you run this year?*

Your Income

Is your total annual income:*

Under £2,000

£2,000 or more

Your expected income for the next 12 months, including any grants, funding and donations

Your Total Annual Turnover*

Please enter a number greater than or equal to 2000.

If the exact income is not known, please provide an estimation. Include all income, including any grants, funding and donations. If your total turnover is under £2000, then amend your answer to the previous question.

How much of your income is derived from overseas activity*

If the exact income is not known, please provide an estimation.

How much of your income is derived from the advice you provide?*

If the exact income is not known, please provide an estimation.

How much of your income is derived from the sale or repair of goods?*

Your People

Does your organisation have:*

Employees

Volunteers

Members

Trustees / Committee Members

None of the Above

Employees would include any sub contractors, apprenticeships, work placements, self employed individuals and freelancers.

Further Explanation*

Please describe how your group operates without employees, volunteers or members.

Types of Staff*

Clerical Staff

Manual Work Staff

Non Manual Staff

Please select whether you have staff in the following broad categories

Number of Full Time Clerical Employees

Number of Part Time Clerical Employees*

Please count staff as full time equivalents. For example two part time roles of eighteen hours each would equal one FTE.

Clerical Staff – Annual Wageroll

Number of Full Time Manual Work Employees

Number of Part Time Manual Work Employees

Please count staff as full time equivalents. For example two part time roles of eighteen hours each would equal one FTE.

Manual Staff – Annual Wageroll

Number of Full Time Non – Manual Work Employees

Number of Part Time Non-Manual Work Employees

Please count staff as full time equivalents. For example two part time roles of eighteen hours each would equal one FTE.

Non Manual Staff – Annual Wageroll

Total Employees

Total Wageroll

Number of Volunteers*

The total number of people in your volunteer pool.

Number of Active Volunteers*

The highest number of volunteers that might partake in an activity at one single point in time

Total Number of Members*

The total number of people your group considers to have as members.

Number of Active Members*

The highest number of members that might partake in an activity at one single point in time

Trustees / Committee Members*

Are any of your trustees based overseas?*

Yes

No, all UK based

Your Risk Management

Health and Safety (select all that apply)*

None of the below

We have a health and safety policy

We have a health and safety officer

We provide health and safety training to employees and volunteers

We undertake risk assessments

We keep an accident book

We have a manual handling policy

We use appropriate PPE

Does your organisation work with children or vulnerable adults?*

Children

Vulnerable Adults

Both

Neither

General Description – Work with young or vulnerable people*

What work do you do with such groups and how often?

Do you work in the service users home?*

Yes

Is there any 'lone working' with young or vulnerable service users?*

Yes

Do you have a lone worker policy?*

Yes

Do you have a safeguarding policy in place?*

Yes

Are children always under the supervision of a parent / guardian*

Yes

Are all volunteers and employees DBS checked?*

Yes

The Cover you Require

We would recommend £5,000,000 for organisations that work with children or vulnerable adults.

Public Liability Insurance*

Public Liability Insurance: Covers your organisation against claims of injury, illness or property damage suffered by members of the public or volunteers as a result of the charity’s activities.

Working with young people and vulnerable adults, we highly recommend that you select cover for allegations of abuse.

Public Liability Options

Hirer Liability – The ability to extend cover to occasionally hirers of our facility

Cover for allegations of abuse

Liability for the property or land we manage or own

Allegations of libel and slander

Products Liability Insurance*

Required

Not Required

Unsure

You indicated that you supply or sell products and services and we would recommend that you include Products Liability Insurance.

Employers' Liability*

No cover required

£10,000,000 (standard limit)

Unsure

Employers’ Liability Insurance: Covers your organisation against claims from employees (or volunteers) who suffer injury or illness as a result of their work for your organisation. This is compulsory by law if you have employees (and advisable if you have volunteers).

You have volunteers in your organisation. Insurers generally treat volunteers as employees and so Employer Liability insurance is very strongly recommended for you.

Since you have staff, employers liability insurance is a legal requirement for your group.

Professional Indemnity Insurance*

Professional Indemnity Insurance: Covers claims for financial loss or damages resulting from negligent or incorrect advice or professional services by your organisation.

Since you do provide advice, we would recommend this cover is considered.

Professional Indemnity Retroactive Date*

DD dash MM dash YYYY

The retroactive date is the earliest date your professional indemnity policy provides cover for past work. You will find it on your current PI schedule or certificate. If you have not had cover before, then the current date is the earliest you can select.

Management / Trustee Insurance*

Trustee Indemnity Insurance: Otherwise known as Directors & Officers Insurance. This protects your trustees, and your organisation against claims, made against the charity or against a trustee individually, that a trustee committed wrongful acts in the course of running the charity, provided they acted in good faith.

We would strongly recommend that you consider Trustee Indemnity. We can provide pricing separately.

Do you require contents insurance at a fixed location?*

Yes

Contents Insurance: Cover for your organisation’s equipment, furniture, stock or other property against damage or loss from insured risks (dependent on cover) such as fire, theft or accidental damage.

General Contents (£)*

Please indicate the value of any other contents that your group owns

Are any contents stored on ground-floor level?

Yes

Computer and Electronic Equipment*

Please indicate the value of your computer and electronic equipment cover.

Stock*

Please indicate the value of any stock you might have on the premises

Do you want to insure portable equipment (such as laptops and mobiles)?*

Yes

Portable Equipment Insurance: Covers portable equipment against loss, theft or damage, on or off-site.

Value of your portable equipment*

Please indicate the value of items you might regularly remove from your premises

Please describe the equipment you want to insure?

A general description of the equipment and where it is normally kept

Is any equipment ever left out in the open?*

Yes

e.g. at community events

What is the highest value single item of portable equipment?*

Any additional content information?*

Are there any tenant’s improvements? Fixtures and fittings? High value items? Fine art or antiques? Special equipment? Cover required away from premises? Catering equipment? Medical equipment? Fridges/freezers and refrigerated contents? Where are contents stored?

Do you require buildings insurance?*

Yes, for one building

Yes, for multiple buildings/locations

Buildings Insurance: Cover for property against damage or loss from insured events (dependent on cover) such as fire, flood or storm.

Building Sum Insured (£)*

This should represent the full rebuilding costs which would include professional fees and site clearance costs

Buildings Sum Insured Notes*

Further property questions in next section. Last survey? Confident in your sum insured? 80% of UK ‘commercial’ buildings are underinsured. Insurers reduce claim payments of any size if there is underinsurance. Underinsurance and RCA article.

Please select any other cover sections that you require

Legal Expenses

Business Interruption

Personal Accident

Money

Loss of Rental Income

Goods in Transit

Cyber and Data Cover

Fidelity or Fraud

Medical Malpractice

Employment Practice Liability

Loss of License

Engineering Cover

You do not need legal expenses cover to cover your legal costs for defending a liability claim. Personal Accident is a benefit for volunteers and employees. If an allegation of fault exists then it is liablity insurance that would respond.

We would recommend that you consider Loss of Licence cover as an organisation.

Property and Security Details

Is the building address the same as the main location address?*

Yes

Address of Building Insured*

Postcode

9VZ2-JSWC-S4HE-3RNU

DaviDoyle882157

Select an Address:

Street Address Address Line 2 City County

What is the general use of the building?*

Is any part of the building currently or expected to be unoccupied?*

Yes, partially unoccupied

Yes, fully unoccupied

No, but expected to be unoccupied

Unoccupancy:
– No persons are living in, working in, or conducting normal business operations at the premises for 30 days.
– The property’s intended use has ceased, even if occasional visits occur (e.g., cleaning, inspections, or maintenance do not count as occupation).
– Buildings containing stock, equipment, or contents are effectively empty of normal operational activity.

Is the building in a good state of repair?*

Yes

Details of unoccupancy*

Expected unoccupancy, maximum period of unoccupancy, details.

What year was the building constructed?*

Is the building listed?*

Construction of Walls*

Construction of Roof*

Does the building have any flat roofed areas?*

Yes

What % of the roof area is flat?*

Do final exit doors have 5 lever mortice deadlocks complying with BS3621?*

Yes

Unsure

Do all accessible opening windows have key operated locks?*

Yes

Unsure

Do you have an alarm system on the building?*

Yes

Unsure

Does your alarm have a signalling mechanism?*

Digital Communicator

Central Police Station

Unsure

Does the alarm have a maintenance contract?*

Yes

Unsure

Do you operate a CCTV system for your premises?*

Yes

Do you have an automatic fire alarm linked to a Central Station and fully maintained fire extinguishers?*

Yes

Do you live on or adjacent to the premises?*

Yes

Please provide any other construction or security details that you feel are relevant*

Floors:
Number of floors | Floor construction | Occupancy details of floors

Composite panels:
Type of insurance core in panels | Proportional of overall wall area | Proportion of overall roof area

Fire:
Fire Risk Assessment | Type of heating | Commerical/domestic kitchens | Deep fat fryers | Volume of flammable liquid | Insulation OTHER:
Non-ferrous materials
Heating
Grade listing
Good state of repair
Outbuildings
Planned works
Shutters or other security features

Property risks and history*

FLOOD:
1. Any history of flooding at the premises? (dates/cost/details)
2. Any flooding in the surrounding area within last 10 years?
3. Near a water source? | Within 250m of river, stream, sea, or tidal water?
4. Basement present? Used for storage?
5. Critical services (electrics/IT/boilers) at ground floor or below?
6. Flood resilience measures in place (barriers, pumps, raised sockets etc.)?
7. Formal flood plan in place?

SUBSIDENCE RISK:
1. Any history of subsidence, heave, or landslip? (dates/details)
2. Any ongoing movement or monitoring?
3. Any underpinning carried out? (date & completion certificate available?)
4. Trees within influencing distance of building?
5. Property built on known shrinkable clay? 6. Any neighbouring properties affected?

Are there any additional buildings/contents cover options to be considered?

Subsidence

Flood

Land

Terrorism

Acres of Land*

How many acres of land should be insured?

What is the land used for?*

Do you own or lease the land?
Is it used for recreation, agriculture, car park, other?
Is public access allowed?
Any history of flooding, landslip, subsidence, unstable ground?
Any contamination or pollution on site?
Any trees, embankments, steep slopes?
Boundaries: Fences, gates, rights of way?
Are there outbuildings, structures, sheds, greenhouses, playgrounds?
Are there any water features on site?
Any livestock or animals present?
Any previous claims relating to land?

Are there any interested parties?*

Interested party | Property | Nature of interest | Agreement Number

Any details about the multiple buildings/locations?*

Details of locations, construction of walls, roof, deadlocks, alarms, signalling mechanisms, CCTV, security, fire alarms. Living on or next to premises? Outbuildings, flood or subsidence risks.

Claims

Have you made any claims or suffered any losses (of any nature) in the last 10 years?*

Yes

Are there any circumstances within your organisation that could currently reasonably lead to a loss?*

Yes

Any known circumstances that might develop into a loss whether insured or not

Please describe the circumstances of your loss or claim*

Please include the date, circumstances and financial loss. How did your insurer respond to the claim? Were there any claims that were not covered? How did you find the experience? Any mitigation against a future occurrence happening?

Adverse History Declarations

Has the organisation ever been refused insurance cover, had cover cancelled or special terms applied by an insurer?*

Yes

Adverse Insurance Details*

Type of issue (Cancellation, voidance, refusal or special terms imposed) | Reason given by insurer (non disclosure, claims losses, or risk improvements) |Date of issue | Insurer involved | | Position (Resolved new terms agreed or ongoing)

Have any of your trustees, directors, partners, committee members, either as private individuals or in connection with any business or organisation:*

a. Been the subject of any adverse publicity in the last 5 years, or anticipate being the subject of any adverse publicity in the next 12 months?

b. Been designated or specified under the Sanctions and Anti-Money Laundering Act 2018, or any similar sanctions list provided by the United Nations, European Union or the United States of America?

c. Ever been convicted of a criminal offence other than motoring offences?

d. Ever been declared bankrupt or have any unsatisfied County Court Judgement against them?

e. Been the subject of a prosecution, or notice of intended prosecution, under any health and safety at work, consumer protection or environmental legislation or investigation in the last three years by the Charity Commission, Revenue & Customs or any other regulatory body?

None of the above

Adverse Publicity Details*

Sanction List Details*

Criminal Offence Details*

Financial Declaration Details*

Nature of the issue | Date of the issue | Month and year if possible | Current status (satisfied, resolved, ongoing) | Role of the individual involved (We do not need the name of the individual at this stage)

Investigations / Prosecutions Details*

Which regulator or authority involved? | Nature of the investigation / prosecution Date of investigation | Outcome or current position (closed, ongoing, improvement required)

Fair Presentation

Before entering into a contract of insurance, it is your statutory duty to make a fair presentation of your risk. You have a duty to disclose all material facts that may influence an insurer’s decision to provide coverage or set premiums. Failure to do so may result in denial of claims or cancellation of my policy.

Do you feel that the details you have entered are a fair presentation of your insurance risk?*

Yes

Please detail any additional facts or circumstances.*

Would you like to receive emails from Access Insurance about updates, risk management resources and webinars?*

Yes