Application form liabilty insurance

Company information

1. Bedrijfsnaam

2. Handelsnaam (indien anders)

3. Bedrijf adres

4. Postcode

5. Nummer Kamer van Koophandel (KvK)

6. Website

7. Locaties (indien anders dan bovenstaand)

8. Bedrijfsnamen om te verzekeren

9. (Leg svp de verbondenheid uit)

10. Please describe your activities as a (group of) company (companies), per insured entity (hoedanigheid)

Financial information

Please provide the following information for the past, current and future financial years:

11. Turnover past financial year (in €)

12. Turnover current financial year - estimated (in €)

13. Turnover next financial year - expected (in €)

14. Total number of employees

Employees division

Enter the ratio of your employees below:

15. Clerical / Managerial staff not involved in manual work %

16. Sales and marketing (in %)

17. Laboratory Workers (in %)

18. Manual workers (in %)

19. Other - please describe (in %)

20. Total estimated wage roll (in €)

21. Was a Risk Inventarisation and Evaluation (RI&E) survey performed? If yes, please attach report.

Yes
No

22. If yes: please upload your RI&E.

23. Do any of the applicant’s employees provide direct patient care?

Yes
No

24. Do they carry their own individual medical professional liability coverage?

Yes
No

25. Does the applicant operate an inpatient facility?

Yes
No

26. Does the applicant or its employees have a financial interest in the products of the applicants clients?

Yes
No

27. Is there a Clinical Trial planned in this or next year?

Yes
No

28. List new products expected to be introduced.

29. List any discontinued products. (please indicate reason(s)

Historic loss

30. Do you have any historic losses and/or circumstances that can lead to a loss?

Yes
No

31. If yes, please describe

32. Please enclose any documents, lists or explanations, as required, in response to various questions throughout the body if this insurance proposal. Please also provide copies of the following: Marketing or advertising brochures or descriptive mater.

33. Agreement for application.

I give hereby my agreement for this application.

34. Name

35. Position in company

36. E-mail

37. Telephone number

38. Date

Declaration

I/we declare that, after full enquiry, the contents of this proposal are true and that I/we have not misstated, omitted or suppressed any material fact or information. I/we agree that this proposal together with any other information supplied by me/us shall form the basis of any contract of insurance which may be effected. If there is any material alteration to the facts and information which I/we have provided or any new material matter arises before the completion of the contract of Insurance, I/we undertake to inform Underwriters.

All questions must be answered and the application must be signed and dated.

39. Agreement *

I agree

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